Patient A
An 11-year old female was referred to the pediatric hematology clinic for isolated thrombocytopenia, which was identified after presenting to the emergency department with bilateral toe bruising. Her fingers and toes would become purple for a prolonged period of time, but bleeding symptoms were absent.
Family history was positive for bruising in the mother and anemia in the maternal grandmother. The patient was taking atomoxetine, risperidone, hydroxyzine, and medroxyprogesterone acetate. Physical exam showed cyanosis in the feet after exposure to cold, slow capillary refill, and macular papular red erythematous rashes above the ankles bilaterally.
Complete blood count (CBC), screening coagulation studies, serum immunoglobulins, and autoimmune studies were obtained (Table 1 ). Mild thrombocytopenia with normal sized platelets and normal granulation on peripheral smear was noted. The clinical presentation was most consistent with Raynaud’s, and it was thought that the mildly decreased platelets could have been the result of viral suppression or side effects from risperidone. A repeat CBC one month later was recommended.