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Thrombocytopenia

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by

Callie Davies

on 7 January 2014

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Transcript of Thrombocytopenia

Causes
Decreased Production
Increased Destruction
Dilutional
Distributive

BUT FIRST?
Diagnosis of ITP
Only two criteria are required for its diagnosis :

Thrombocytopenia, with an otherwise normal CBC and WBC differential, including a normal peripheral blood smear
No clinically apparent associated condition(s) or medications that may cause thrombocytopenia are present.
Treatment
Approach to Thrombocytopenia
Ending with Diagnosis of ITP

Thrombocytopenia
<150,000
Normal 150,000 to 450,000/microL
2.5% have lower than normal
Approach
History
-
new meds, illnesses ect
Physical
- look for:
ecchymosis
occular fundus for evidence of bleeding
Lymphadenopathy/HSM/masses
Stool for occult blood
CBC + peripheral Smear
BM biopsy/HIV testing
Medical Emergency
Even if in normal range if platelet count drops 50% within 5-10 days of starting heparin think HIT

Obviously immediately stop Heparin

If no contraindications immediately start alternative non-heparin (or warfarin) anticoagulant

Platelet #'s
Surgical bleeding
-
50,000/microL
Clinical or spontaneous -bleeding
<10,000 to 20,000/microL.
Spontaneous life threatening bleeding
-
<6000/microL
Decreased Production
Validate the platelet count!
Pseudothrombocytopenia
Clotting of blood
sample

EDTA Clumping
(platelet satellitism)
BM Failure:
acquired- aplastic anemia
congenital- Fanconi's syndrome
BM Invasion:
tumors, leukemia, fibrosis
BM injury:
ETOH, chemo/radiation
Vit B12/folate deficiency
After viral infecion
HIV
Increased Destruction
Immune:
Infection- CMV/Mono
Immune Thrombocytopenic Purpura
SLE/antiphospholipid syndrome
Heparin Induced Thrombocytopenia T1
HIV
Alloimmune Destruction
Drug Induced
Non-Immune
Disseminated Intravascular Coagulation
Thrombotic Throbocytopenic Purpura
HIT- T2
Dilutional
Transfusion
Distributional
Splenic Sequestration
Most Common Drugs
Heparin
Valproic acid
Gold salts
Quinine and quinidine
Trimethoprim-sulfamethoxazole and other sulfonamides
Interferons
Measles-mumps-rubella vaccine
Glycoprotein IIb/IIIa inhibitors (eg, abciximab)
You've got Nothin'
Now What??
Autoimmune antibody (IgG) formation against host platelets. IgG coats and damages platelets which are then removed by splenic macrophages

However
, these antibodies are not easily demonstrable in all patients, and assays for antiplatelet antibodies have not been important for management decisions.

Pathogenesis
Types of ITP
Primary
if it has no underlying cause
Secondary
if it is immune mediated but associated with an underlying disorder
Chronic
has lasted for more than 12 months
Refractory
if it has failed to respond to (or relapsed after) splenectomy and is severe (ie, associated with bleeding or bleeding risk that requires therapy).
Symptoms
Petechiae and ecchymosis on the skin but many patients will have minimal bleeding symptoms despite extremely low platelet counts (<5,000)

Bleeding of mucous membranes
NO Splenomegaly!
LABS
Platelet count typically

<20,000
Other blood count

normal
Peripheral Smear

shows
decreased platelets
BM aspiration shows
increased megakaryocytes
Increased amount of
platelet-associated

IgG
IVIG may be used instead of glucocorticoids when a more rapid increase in platelet count is required
Induces Remission in 70-80% of Chronic ITP cases
Thrombopoietin receptor agonists:
Romiplastim
Eltrombopag
**Platelet transfusions for life threatening and serious hemorrhagic episodes
KEY POINT??
**Avoid unnecessary treatment of asymptomatic patients with mild to moderate thrombocytopenia!!
When to worry about bleeding?
---Callie Davies MSIII---
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