Mahmood Dhahir Al-Mendalawi1. 1. Department of Paediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad, Iraq. E-mail: mdalmendalawi@yahoo.com.
Sir,I read with interest the case report by Barara and Garg on a child with systemic lupus erythematosus (SLE) who was initially presented with thrombocytopenia and diagnosed as idiopathic thrombocytopenic purpura (ITP).[1] It is worthy to mention that assessing pediatric patients, with thrombocytopenia represents a major challenge in the clinical settings as 15% of ITP patients in India, have been noticed to fulfill the diagnosis of SLE on detailed evaluation.[2] Barara and Garg stated in their study that the presence of high titer of anti-nuclear antibodies (ANA) is a sensitive marker for future development of SLE in patients with ITP.[1] They did not support that notion with references. Reviewing the literature revealed that only two studies that did not support the contribution of ANA titer to the prediction of SLE in ITP patients. The first study involved a retrospective analysis of 365 children and 108 adult patients with ITP and patients found to have positive ANA were regularly followed up for a mean of 3.6 years (range: 2.1–7 years) for the development of symptoms indicative of autoimmune disorders. The study showed that ANA positivity was often found in adult and childrenpatients with ITP and indicated that the detection of ANA positivity was not enough to identify those patients with ITP who are at risk of developing SLE or other connective tissue diseases. Moreover, there was a statistically significant difference in terms of ANA positivity between childhood acute and chronic ITP patients. The study concluded that ANA positivity might be an indicator in terms of chronicity for childhood ITP.[3] The second study recruited 222 children with ITP who were followed for a mean of 4.2 ± 4.9 years. The study revealed that the majority of children with ITP who had a positive ANA (64%) did not develop SLE.[4] I, therefore, presume that it is essential to periodically monitor ITP patients for other clinical data of SLE rather than solely relying on ANA titer serial measurement. Apart from scrutinizing ITP patients for cutaneous lesions as recommended by Barara and Garg,[1] fever and arthralgia are additionally paramount to be regularly checked as they were proved to be the most predominant clinical characteristics in Indian SLE pediatric patients.[2]