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Intravenous immunoglobulin
0%
0/7
Observation
71%
5/7
Platelet transfusion
Prednisone
Rituximab
29%
2/7
Select Answer to see Preferred Response
This patient is presenting with isolated thrombocytopenia with no other clear cause for this abnormality; therefore, the most likely diagnosis is immune thrombocytopenic purpura (ITP). Given his absence of bleeding (currently) and low platelet count, observation and monitoring is the only treatment that is needed. ITP is an autoimmune condition that can coexist with other autoimmune disorders or stand alone. The diagnosis is based on the presence of an isolated low platelet count, absence of other etiologies for a low platelet count (especially medications, acute infection/systemic illness, or chronic viral infection), and absence of platelet clumping (pseudothrombocytopenia) on peripheral blood smear. For patients without active bleeding and a platelet count greater than 30,000/uL, expectant management is appropriate. This condition generally resolves on its own. Figure A is the physical examination finding of petechiae (with bruising) that can be seen when there is a low platelet count. Incorrect Answers: Answer 1: IVIG is generally used to rapidly increase a patient's platelet count, such as prior to a procedure or in the case of severe thrombocytopenia (platelet count < 10,000/uL). It could be indicated if this patient was experiencing acute bleeding (not just bruising and petechiae) or if he had a severely low platelet count (though asymptomatic patients with very low platelet counts often do not require treatment). Answer 3: Platelet transfusion is typically withheld unless major bleeding (such as intracranial bleeding or severe GI bleeding) is present. Platelets are generally rapidly consumed in this condition thus their indication only in bleeding. Answer 4: Prednisone can be indicated in the management of ITP and may be appropriate if the platelet count is < 10,000 or in combination with other treatments (IVIG) for more severe presentations (bleeding). It would not be indicated in an asymptomatic patient with a platelet count > 30,000. Answer 5: Rituximab has shown promise in the treatment of ITP but is generally reserved as a second-line treatment. Bullet Summary: Asymptomatic patients with ITP with a platelet count > 30,000/uL require only observation.
3.7
(16)
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