Updated: 6/30/2020

Immune Thrombocytopenia (ITP)

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Snapshot
  • A 42-year-old man presents to his primary care physician's office for easy bruising and gingival bleeding. He reports his symptoms began one day prior to presentation and has never occurred before. Medical history is significant for a recently diagnosed hepatitis C infection. On physical exam, there is mild bleeding of the gums. There are petechiae throughout the chest, arms, and legs. There is no evidence of splenomegaly on abdominal exam. A complete blood count is significant for a platelet count of 24,000/μL and peripheral blood smear demonstrates enlarged platelets. He is started on corticosteroids.
Introduction
  • Clinical definition
    • acquired immune-mediated destruction of otherwise normal platelets
  • Classification
    • primary immune thrombocytopenia (ITP)
      • immune-mediated thrombocytopenia without an underlying condition
    • secondary ITP
      • immune-mediated thrombocytopenia with an underlying condition (e.g., HIV infection)
  • Epidemiology
    • demographics
      • 1-7 years of age commonly in children
  • Etiology
    • primary ITP
      • unknown
    • secondary ITP
      • autoimmune disorders
        • systemic lupus erythematosus
        • antiphospholipid syndrome
      • infection  
        • HIV
        • hepatitis C virus
      • malignancy
        • chronic lymphocytic leukemia
      • vaccinations
  • Pathogenesis
    • IgG antibodies directed against platelet membrane glycoproteins such as GPIIb/IIIa
      • a type II hypersensitivity reaction
Presentation
  • Symptoms
    • asymptomatic
    • bleeding symptoms
      • gingival bleeding
      • epistaxis
  • Physical exam
    • petechiae
    • purpura
    • ecchymosis
    • atypical to have a palpable spleen
Studies
  • Making the diagnosis
    • primary ITP
      • isolated thrombocytopenia (e.g., < 100,000/μL) without a known cause
    • secondary ITP
      • isolated thrombocytopenia (e.g., < 100,000/μL) with an underlying condition (e.g., positive for HIV infection)
Differential
  • Hypersplenism
    • distinguishing factor
      • splenomegaly
  • Liver disease
    • distinguishing factor
      • elevated transaminases and hepatosplenomegaly
      • coagulation abnormalities may be present
  • Microangiopathic hemolytic process (e.g., thrombotic thrombocytopenic purpura)
    • distinguishing factor
      • schistocytes are appreciated on peripheral blood smear
Treatment
  • Conservative
    • observation 
      • indication
        • in patients with a platelet count > 30,000/μL and no bleeding 
  • Medical
    • corticosteroids 
      • indication
        • initial treatment for patients with a platelet count < 30,000/μL
    • intravenous immunoglobulins (IVIG)  
      • indication
        • for patients with a platelet count < 30,000/μL who have contraindications to corticosteroids, are refractory to corticosteroid treatment, or are bleeding or have a high risk of bleeding that will need a rapid increase in platelet count
  • Operative
    • splenectomy
      • indication
        • second-line treatment for patients with refractory ITP
Complications
  • Fatal hemorrhage
 

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(M3.HE.15.52) A 66-year-old man presents to his primary care physician endorsing easy bleeding. He reports that roughly 5 days ago, he began noticing excessive bleeding while brushing his teeth. He has not noticed any bleeding since this event and is currently asymptomatic. He is otherwise healthy with a medical history including hypertension treated with amlodipine and depression for which he takes fluoxetine. On examination, he is well appearing. His lower extremities are notable for the finding in Figure A. No active bleeding is seen in his oropharynx and rectal exam is negative for occult blood. Laboratory studies are ordered as seen below.

Hemoglobin: 15 g/dL
Hematocrit: 44%
Leukocyte count: 7,500/mm^3 with normal differential
Platelet count: 31,000/mm^3

Which of the following is the most appropriate next step in management?
Tested Concept

QID: 102993
FIGURES:
1

Intravenous immunoglobulin

0%

(0/6)

2

Observation

67%

(4/6)

3

Platelet transfusion

0%

(0/6)

4

Prednisone

0%

(0/6)

5

Rituximab

33%

(2/6)

M 11 E

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