Home Uncategorized Immune Thrombocytopenia
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

24 year old lady presented with complaints of:

  1. Increased duration of menstrual flow, associated with passage of clots for 13days.
  2. Bleeding gums lasting for around 5 days associated with bleeding from lips.
  3. 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

General:
Moderately built and nourished.
Pallor- Grade 3
Mucocutaneous bleed present.
Petechial rash present over left thigh and palate.  

Vitals:
PR : 104bpm
BP : 130/90mmHg 
RR : 27cycles/min
SpO2 : 96%  

Systemic:  
CVS: S1 S2 heard,      
sinus tachycardia,
no murmurs.  
RS: Normal.  
PA : Soft. 
No  organomegaly  
CNS: Conscious, oriented.

Blood:
Hb: 6.4gm/dl
TLC: 21390cells/cumm
RBC count: 2.72million/cumm
Platelet count: 0.04lakh/cumm
Reticulocyte count: 3.0%
MCV: 76.8fl
MCH: 23.5pg
MCHC: 30.6gm/dl
PT: 14.4
APTT: 23.5  

Iron profile:
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  

Others:
HCV/HIV/HBsAg: Negative
Dengue NS1: Negative
Dengue IgM Ab: Negative
Weil Felix Test: Negative
ANA: 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:
Hb: 7.6gm/dl
TLC: 12540cells/cumm
Platelet count: 1.86lakh/cumm

Idiopathic thrombocytopenic Purpura (ITP) with Severe Anemia

PRBC Transfusion
Platelet Transfusion
Tranexamic acid(1gm IV) *6 days
Dexamethasone(4mg IV) * 2 days Followed by
Prednisolone(40mg)*5 days
9Azathioprine(50mg) * 5 days
Romiplostim(250mcg stat inj)
Iron Supplementation  

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.[1]  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.[2]  

The diagnosis remains one of exclusion, after other thrombocytopenic disorders are ruled out based on history, physical examination, and laboratory evaluation. [3] Diagnosis is by doing Bone marrow study Which shows Giant Megakaryocytes with increased number of Megakaryocytes[4]  

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

  1. Cooper N, Bussel J. The pathogenesis of immune thrombocytopaenic purpura. Br J Haematol.2006;133:364-374.
  2. 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.
  3. Cines DB, McMillan R. Management of adult idiopathic thrombocytopenic purpura. Annu Rev Med. 2005;56:425–42.
  4. Cines DB, Bussel JB. How I treat idiopathic thrombocytopenic purpura (ITP) Blood. 2005;106:2244–51.

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