DISCUSSION
In the setting of positive serologic Lyme Disease testing, hemarthrosis
was thought to be secondary to Lyme arthritis causing joint inflammation
and bleeding symptoms exacerbated by concurrent ITP. Spontaneous
hemarthrosis in ITP is an atypical presentation with the most common
bleeding symptoms being mucocutaneous. It is of utmost importance to
expedite therapy for hemarthrosis to prevent further joint damage.
Initial differential was broad and included ITP, thrombotic
thrombocytopenic purpura, disseminated intravascular coagulation,
hemolytic uremic syndrome, hemophilia, septic or inflammatory arthritis,
bursitis, intra-articular venous malformations, or trauma7,9,13.
Upon reflection, a unifying explanation for the presentation is Lyme
Disease with resultant inflammatory arthritis and severe
thrombocytopenia as causative of the hemarthrosis. The initial symptom
improvement was thought to be due to the anti-inflammatory effects of
the steroid regimen without treatment of additional underlying disease.
Realizing an additional contributing etiology, oligoarticular or
monoarticular joint inflammation must be considered as an unrecognized
cause for spontaneous hemarthrosis in a child with severe ITP.
This provides an example for clinicians to consider when evaluating
abnormal bleeding presentations of ITP. It is important to keep a high
index of suspicion for other treatable conditions. Limitations of this
report include the inability to establish a causal relationship between
the various disease processes occurring in this patient. A single case
report limits generalizability, especially given the geographic
distribution of Lyme Disease in the northeastern and north central
United
States11.
Also, further diagnostic testing via magnetic resonance imaging or
arthroscopy was not pursued to rule out additional
pathology8,9.
In conclusion, this report depicts a rare complication of ITP and
suggests that additional underlying pathology may contribute to abnormal
presentations with severe bleeding symptoms. Providers should be mindful
of additional precipitating causes and consider appropriate testing to
reduce overall morbidity and improve long-term outcomes.