All is well... until the side effects start showing up

Makenna* was a lively six-year-old who came home from kindergarten on Friday afternoon with a bruise on her arm after a fall in the sand pit.

She didn’t appear to be in pain and she denied being injured during play. Her dad made a mental note to jot this in her diary to alert the teacher. She completed her reading, had dinner and was promptly in bed by eight.

Makenna’s dad was a single father who idolised his daughter. The two had survived the tragedy of losing Makenna’s mother four years back to a drunk driver on a Friday night as she was getting back home from a late shift at work.

The two clung to each other during the black days that followed. And they were pretty dark, those days; worse during the night when Makenna would only fall asleep in daddy’s arms and would not agree to be put in her crib. For the next year, the two co-slept while struggling to claw their way out of the deep sense of loss they shared.

Starting kindergarten was the lifeline Makenna needed. She thrived, came out of her shell, made new friends and regained her curiosity. The transformation rubbed off on her dad and he too began to find his footing. He focused on Makenna and his business and both bloomed from the attention. He was grateful for Nani*, Makenna’s nanny from birth, who stuck with them through it all despite advancing age. She was the grandma Makenna never had.

The next morning, Nani declared that Makenna was going to the hospital after breakfast. Everyone had long learnt never to argue with Nani. She asked Makenna to open her mouth and dad agreed with her. Makenna’s mouth was covered in dark red spots all over. Though she felt no pain, Nani had noticed the spots when helping her brush her teeth. Further, there was also bleeding of the gums caused by Makenna’s toothbrush.

The consultation with the doctor was fairly brief. Makenna was admitted to the ward for review by a haematologist. A blood sample taken to the lab revealed that Makenna’s platelet counts were extremely low. These tiny cells in our blood are responsible for making sure that in the event of injury to our blood vessels, they quickly initiate the process of clotting to prevent further blood loss. For effective function, we have at least 150,000 to 450,000 of these per microliter of blood.

ACCURATE DIAGNOSIS

At admission, Makenna had only 4,000. This was the reason she would bleed spontaneously under her skin and mucous membranes. She was in the red zone, with a risk of spontaneous bleeding into the brain that could easily kill her.

A week later, following a host of tests to establish an accurate diagnosis, Makenna was thought to have auto-immune thrombocytopenic purpura. This is essentially a diagnosis reached following exclusion of all other possible causes of low platelets. In children, it commonly occurs following a mild viral infection. The child’s body forms antibodies against the platelets, triggered by the infection. The antibodies coat the platelets and lead to their destruction. Unfortunately, the bone marrow is not able to replace them fast enough.

For most children, this condition may be short-lived and other than close follow-up, will not require any treatment. However, in Makenna’s case, she had to take medication for quite a while. During admission, she was put on high dose steroid drugs and this resulted in improvement of the platelet counts, easing her out of the red zone. However, these steroids cannot be stopped suddenly, hence the long-standing outpatient follow-up as the doses were gradually tapered off while watching for the platelet counts not to plummet again.

Makenna tolerated the medication well and was back to school, regaling her friends with stories of her hospital experience. Every Thursday she came into clinic with her blood test results, hoping for further reduction of her medication.

However, while her results remained encouraging, her father and Nani were dealing with a whole new problem. Makenna was gaining at least a kilogramme at every visit. Nani was initially excited that she was eating so well but this quickly transformed into concern when Makenna would wake her up in the middle of the night with hunger. She had to pack twice as much food in her lunchbox to tide her over during the school hours, yet when she got home, her first stop would be the refrigerator to find something to eat.

WEIGHT CHANGES

Somehow in the initial anxiety to stabilise Makenna, the doctor forgot to inform them that the steroid medication results in drastic increase in appetite as a side effect. Nani wanted an assurance that Makenna would go back to her normal self after discontinuation of treatment. They had been forced to buy a whole new wardrobe for Makenna and it looked like this too would require replacement if the trend continued. She did not think a rounded moon-shape was appropriate for Makenna’s face either.

Alongside the weight changes, children may also have trouble sleeping, mood swings, hyper-activity and stomach discomfort. Luckily, Makenna did not experience these, much to the relief of her loved ones. After eight long weeks, Makenna was officially off medication. Subsequent weekly follow-up tests revealed she was slaying the dragon with a long name that was too much of a mouthful for her to pronounce.

It was with great relief when she began to lose the weight she had piled on. She was back to her usual food potions and she longed to fit into her old clothes. The day she was able to fit into her favourite ‘Frozen’ jeans, she proudly announced that she was cured and did not need any more weekly visits. She was right. Though Makenna continued to see the doctor for the rest of the year, the visits were far less frequent and her test results continued to affirm that, indeed, she had laid autoimmune thrombocytopenic purpura to rest.

Dr Bosire is an obstetrician/gynaecologist