Today’s intern morning report presented by Percy Genyk involved a case of a 59 year old female presenting with oral bleeding and petechiae, found to have a platelet level<5 and is diagnosed with primary ITP.
When approaching a patent with bleeding, think about whether it is more likely related to platelet problem or the coagulation cascade. Coagulation disorders are more likely to present with large ecchymoses and soft tissue hematomas whereas platelet disorders present with epistaxis, gingival bleeding, superficial ecchymoses and petechiae.
Remember that ITP is a diagnosis of exclusion and other causes of thrombocytopenia need to ruled out first.
– A thorough history is necessary to search for medications, infections or other systemic conditions (rheumatologic, chronic liver disease) that may cause thrombocytopenia. Although history/exam/labs would be suggestive, always keep in mind the more emergent causes associated with thrombocytopenia such as thrombotic microangiopathies and DIC.
– A peripheral smear should be ordered in all patients with thrombocytopenia, which will also help evaluate for pseudothrombocytopenia.
– Broad routine work-up of ITP is not needed and guidelines recommend ordering peripheral smear, HIV and HCV only unless history is suggestive of other underlying conditions. Routine bone marrow biopsy is not recommended.
– Routine bone marrow biopsy is not recommended in the work up of ITP.
**Platelet transfusion is not indicated unless the patient is actively bleeding or has severely low platelets.
**Treatment of ITP is not indicated in all patients and is generally reserved for those with bleeding or platelet count less than 30,000. First line therapy includes glucocorticoids and IVIG.
Here is a quick reference with some important pearls on thrombocytopenia!