24 year old lady presented with complaints of:
- Increased duration of menstrual flow, associated with passage of clots for 13days.
- Bleeding gums lasting for around 5 days associated with bleeding from lips.
- Small red brown colored rashes present all over the body.
Patient was previously treated elsewhere and was found to have severe anemia and thrombocytopenia where she received 3 units of packed red cells (PRBC) and 4 units of random donor platelet concentrate (RDP), and was referred to JSS Hospital for further management.
No history of fever
No history of any allergy.
No similar complaints in the past.
No other comorbidities like DM, HTN, Thyroid or Asthma
No past h/o menstrual irregularities
Moderately built and nourished.
Pallor- Grade 3
Mucocutaneous bleed present.
Petechial rash present over left thigh and palate.
PR : 104bpm
BP : 130/90mmHg
RR : 27cycles/min
SpO2 : 96%
CVS: S1 S2 heard,
PA : Soft.
CNS: Conscious, oriented.
RBC count: 2.72million/cumm
Platelet count: 0.04lakh/cumm
Reticulocyte count: 3.0%
Iron: 35.54ug/dl (50-170ug/dl)
Tibc: 349ug/dl (270-450ug/dl)
Ferritin: 61.28ng/ml (10-120ng/ml)
PCV: 25.5% (36-46%)
Bleeding time: 10 min(2-5 minutes)
Clotting time: 9 min (3-8 minutes)
Peripheral Blood Smear:
Microcytic Hypochromic Anemia with neutrophilic leukocytosis and thrombocytopenia
Dengue NS1: Negative
Dengue IgM Ab: Negative
Weil Felix Test: Negative
Direct Coombs Test: Negative
Urine Routine : Normal
LFT, RFT: Normal
Thyroid Profile: Normal
Bone marrow Study: Normocellular marrow with megakaryocytic hyperplasia suggestive of peripheral platelet destruction.
Ultrasound Abdomen and pelvis: Within Normal Limits
At the time of discharge:
Platelet count: 1.86lakh/cumm
Idiopathic thrombocytopenic Purpura (ITP) with Severe Anemia
|PRBC Transfusion |
Tranexamic acid(1gm IV) *6 days
Dexamethasone(4mg IV) * 2 days Followed by
9Azathioprine(50mg) * 5 days
Romiplostim(250mcg stat inj)
Advice on Discharge:
Azathioprine (50mg)*30 days (1-0-0)
Prednisolone(40mg to taper 5mg every 5th day) (1-0-0)
Protein powder (1-0-1) (2tsp in a glass of milk)
Iron + Folic acid tab (1-0-0)* 1 month
Calcium + Vitamin tab (0-1-0)* 1 month
|Immune thrombocytopenic purpura (ITP), also known as idiopathic thrombocytopenic purpura, is an immune-mediated acquired disease of adults and children characterized by transient or persistent decrease of the platelet count and, depending upon the degree of thrombocytopenia, increased risk of bleeding. Petechia, purpura, and easy bruising are expected in ITP. Less common are epistaxis, gingival bleeding, and menorrhagia. Uncommon findings are gastrointestinal (GI) bleeding, gross hematuria and intracranial hemorrhage. |
The diagnosis remains one of exclusion, after other thrombocytopenic disorders are ruled out based on history, physical examination, and laboratory evaluation.  Diagnosis is by doing Bone marrow study Which shows Giant Megakaryocytes with increased number of Megakaryocytes
There are many treatment options.
Initial Treatment Prednisone (7-10 days) or Dexamethasone(4 days every 2 weeks for 4 cycles) + IVIG(2 days) or Anti-D +Platelets(if bleeding)
Relapsed/Persistent ITP Rituximab(iv weekly for 4wks) or Anti-D or IVIG(iv for 2days) or Romiplostim/Eltrombopag
Persistent/Worsening ITP Azathioprine/danazol or Cyclosporine or chemotherapy. Splenectomy
- Cooper N, Bussel J. The pathogenesis of immune thrombocytopaenic purpura. Br J Haematol.2006;133:364-374.
- Kuwana M, Okazaki Y, Satoh T, Asahi A, Kajihara M, Ikeda Y. Initial laboratory findings useful for predicting the diagnosis of idiopathic thrombocytopenic purpura. Am J Med. 2005;118:1026–33.
- Cines DB, McMillan R. Management of adult idiopathic thrombocytopenic purpura. Annu Rev Med. 2005;56:425–42.
- Cines DB, Bussel JB. How I treat idiopathic thrombocytopenic purpura (ITP) Blood. 2005;106:2244–51.