Unknown

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Unknown 128
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Case Presentation

• A 32-year-old woman is evaluated during a routine
  examination. She feels well and takes no
  medications. She has not had excessive bruising,
  epistaxis, or gingival bleeding. She is not
  pregnant. Her medical history is otherwise
  noncontributory.

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Physical Exam

• Vitals 120/80, 85, 16, 98 RA
• Gen NAD
• CV RRR, S1, S2
• Pulm no m/r/g
• Abd no HSM
• Ext no c/c/e

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Labs

• 14
• 7.2 52
• 39
• Peripheral smear decreased of platelets but
  otherwise normal peripheral smear
• HIV - negative

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Question

• Which of the following is the most appropriate
  next step in the management of this patient?
• Antiplatelet antibody measurement
• Bone marrow examination
• Trial of prednisone
• Periodic monitoring of platelet count

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Answer
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Question

• Which of the following is the most appropriate
  next step in the management of this patient?
• Antiplatelet antibody measurement
• Bone marrow examination
• Trial of prednisone
• Periodic monitoring of platelet count

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Immune (idiopathic) thrombocytopenic purpura

• Pathogenesis
• Likely platelet destruction or inhibition of
  platelet production by IgG autoantibodies to
  patient B cells
• Incidence
• 22/1,000,000 in symptomatic patients

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Clinical Manifestations

• Petechiae, purpura, easy bruising
• Epistaxix, gingival bleeding, menorrhagia

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Diagnosis and Management of ITP

• Diagnosis based primarily on history, physical,
  and exclusion without a gold-standard test to
  confirm the diagnosis
• Diagnostic Criteria
• Isolated thrombocytopenia with otherwise normal
  blood counts and normal peripheral smear
• No clinically apparent associated conditions that
  can cause thrombocytopenia

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Initial Studies

• History
• Physical
• CBC
• Peripheral smear
• Exclude pseudothrombocytopenia
• Congenital disorders
• Cold dependent agglutinins
• schistocytes

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Any Further studies

• HIV or Hepatitis C testing in patient with
  appropriate risk factors

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What about other labs / studies?

• Bone marrow aspiration?
• Reserve for patients gt 60 y.o. to evaluate for
  myelodysplastic syndrome
• Antiplatelet antibody testing?
• Not recommended

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Treatment of ITP

• Goal is to prevent major bleeding, which usually
  occurs at levels below 10,000
• Patients who have mild, asymptomatic, incidental
  thrombocytopenia should not be treated.
• Treatment is usually reserved for patients with
  moderate or severe thrombocytopenia who are at
  bleeding risk.

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Treatment, contd

• Prednisone 1 mg/kg PO as a single daily dose
• IVIG / anti-Rh (D)
• Splenectomy

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Objectives

• Diagnose and treat a patient with idiopathic
  thrombocytopenic purpura.