THROMBOCYTOPENIA

PRESENTED BY: BASIL AL-SAIGH, FMR – 1

SUPERVISORS: DR. ESSALAH

DR. RUTHNUM

DR. DATTA

AGENDA

• AN APPROACH TO THROMBOCYTOPENIA (5 STEPS)

• 3 CASE REPORTS FROM 4F– PATIENT 1; C/O DR. ESSALAH

– PATIENT 2; C/O DR. RUTHNUM

– PATIENT 3; C/O DR. DATTA & DR. ESSALAH

AN APPROACH TO THROMBOCYTOPENIA (5 STEPS)

AN APPROACH TO THROMBOCYTOPENIA

• “HOW TO INTERPRET AN ABNORMAL COMPLETE BLOOD COUNT”

• MAYO CLINIC PROCEEDINGS JULY 2005; 80(7):923-936

• WWW.MAYOCLINICPROCEEDINGS.COM

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• KEEP IN MIND THAT USING LOW PLT COUNT TO HELP CLINCH A DX MUST BE IN CONJUNCTION WITH OTHER PEX AND LAB FINDINGS

AN APPROACH TO THROMBOCYTOPENIA CONT’D …

• STEP 1

AN APPROACH TO THROMBOCYTOPENIA CONT’D …

• R/O SPURIOUS THROMBOCYTOPENIA (SECOND. TO EDTA-INDUCED PLATLET CLUMPING)

• SOLUTION : EXAMINE THE PBS (LOOKING FOR PLATLET CLUMPING) OR REPEAT THE CBC WITH SODIUM CITRATE AS AN ANTICOAGULANT

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• STEP 2

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• R/O HUS/TTP/DIC

• REASON : THERE IS AN URGENCY FOR SPECIFIC THERAPY IN THESE DISORDERS

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• WHAT TESTS DO WE ORDER FOR DIAGNOSIS OF HUS/TTP?

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• CBC & PBS (ANEMIA & SCHISTOCYETES)

• SERUM HAPTOGLOBIN (DECREASED)

• SERUM LDH (INCREASED)

• SERUM CREATININE (INCREASED)

• COAGULATION TESTS (EXCLUDE DIC)

CASE 1

C/O DR. ESSALAH

PATIENT 1

• BACKGROUND

• PATIENT 1

• 10 Y/O MALE, OTHERWISE HEALTHY

• NON-CONTRIBUTING PMHX, PSHX OR FHX AND NKDA

PATIENT 1

• RFC

• 09/26/05 - C/O LETHARGY, NON-BLOODY DIARRHEA, LOWER ABD. PAIN, NO APPETITE

• 09/28/05 - ABOVE S/S CONT. AND NOW VOMITTING

• NAD ON U/S - OPERATD. ON FOR APPEND

• RFC CONT’D

• POST-OP: ANURIC; CATHETERIZED

• 09/29/05 : NON-BLOODY DIARRHEA OF SAME FREQUENCY; VOMITTING; DECREASED APPETITE; STILL ANURIC

• 09/30/05 : DR. ESALAH CALLED TO ASSESS FOR ANURIA

PATIENT 1

• QUESTION

GIVEN THIS CASE PRESENTATION, WHAT IS YOUR DDX FOR PT. 1?

PATIENT 1

• DDX

• PRE-RENAL FAILURE: SEC. TO VOMITTING AND DIARRHEA

• RENAL FAILURE

• POST-RENAL FAILURE: BILATERAL URETERAL COMPROMISE IN SURGERY

PATIENT 1

• DDX CONT’D

• PRE-RENAL FAILURE : PRE-OP VITALS GOOD; PRE-OP IN/OUT GOOD. UNLIKLEY

• POST-RENAL FAILURE : OPERATION PERFORMED ON THE RIGHT SIDE OF THE ABDOMOEN SO BILATERAL URETERAL COMPLICATION UNLIKLEY

PATIENT 1

• DDX CONT’D

• RENAL FAILURE: THE KIDNEY IS COMPOSED OF 4 COMPARTMENTS:

• THE BLOOD VESSELS (CONSIDER HUS)• THE GLOMERULUS (CONSIDER GN)• THE TUBULES (CONSIDER ATN) - MCC• THE INTERSTITIUM (CONSIDER DRUGS/OTHER)

PATIENT 1

PATIENT 1

• LABS ON ADMISSION

• PLT COUNT : 90• HGB : 140• RET COUNT : 144• LD : 3451• COAG STUDIES : WNL• UREA : 27.5• CREAT : 373

PATIENT 1

• VIRAL STUDIES

• VEROTOXIN : +• SHIG/SALM/C. DIFF/ GP. A STREP : -

•PATIENT 1 HX RE-VISITED

• PRESENTING S/S - MOM NOW STATES THAT PATENT 1 COULD HAVE HAVE SOME EPISODES OF BLOODY DIARRHEA

• SOCIAL HX – IN GRADE 6 AND DOING V. WELL IN SCHOOL; MOM TEACHING PRE-SCHOOL @ HOME; NO KIDS INFECTIVE; DAD ENGINEER

• DIET – BALANCED DIET; EATS BURGERS OCC. @ FRIENDS HOUSE; LAST ATE STEAK/BURGERS FEW DYS BEFORE ADMISSION AND USED MICROWAVE TOO COOK ITIN

PATIENT 1

PATIENT 1

• WORKING DX OF PATIENT 1: HUS

PATIENT 1

• COMPLICATIONS OF HUS

• PHUTS• PANCREATITIS• HEMOLYSIS• HEPATIC DYSFUNCTION• HEART FAILURE• UREMIA (RF)• THROMBOCYTOPENIA• SEIZURES/NEUROLOGICAL DEFICITS

• MANAGEMENT

• HUS CAN CAUSE RF

• RF CAN CAUSE HYPERKALEMIA, HYPERPHOSPHATEMIA, HYPONATREMIA AND HYPOCALCEMIA : ELECTROLYTE BALANCE AND DIET RESTRICTIONS

• RF CAN CAUSE FUID OVERLOAD : FLUID SUPPORT

PATIENT 1

PATIENT 1

• MANAGEMENT CONT’D

• RF CAN CAUSE ANEMIA AND LOW PLT. COUNT: BLOOD AND PLT. TRANSFUSIONS

• DIALYSIS INDICATED FOR REFRACTORY HYPERKALEMIA OR IF ABOVE FAILS TO CORRECT ELECTROLYTE IMBALANCES, SEVERE ACIDOSIS OR SEVERE UREMIA

PATIENT 1

• MANAGEMENT CONT’D

• SCREEN FOR LIVER, PANCREATIC DYSFUNCTION

• MONITOR FOR PLATELET COUNT, RENAL FUNCTION

PATIENT 1

• MGMNT & LABS

• DIALYSIS DONE OCTOBER 2ND, 4TH, 6TH, 8TH FOR SIG. ELEVATED UREA AND CREAT LEVELS

• UREA : 42.9 - 38 - 17.3 - 25.2 - 22.8 - 18.0 - 12.2 - 6.4

• CREAT : 464 - 623 - 715 - 304 - 266 - 552 - 191 - 73

• PLT COUNT : 74 - 26 - 41 - 101 - 146 - 242 - 449 - 281

PATIENT 1

• MGMNT & LABS

• HGB : 106 - 82 - 104 - 93 - 107 - 82 - 74 - 76 - 71

• LD : 4098 - 1984 - 1174

• NA AND K : WNL

• AMYLASE : 153 - 164 - 113

• LFT : WNL

PATIENT 1

• D/C HOME 10/20/05

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• STEP 3

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• CONSIDER HYPERSPLENISM

• CONSIDER DRUG-INDUCED THROMBOCYTOPENIA

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• WHAT PEDIATRIC CONDITIONS CAUSE HYPERSPLENISM?

• BANTI’S

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• BLOOD FLOW PROBLEM

• MOA

• INC. SPLENIC VEIN PRESSURE CAUSING CONGESTION

• EXAMPLES

• SPLENIC VEIN THROMBOSIS EX. TRAUMA,

• PORTAL VEIN THROMOSIS FROM HYPERCOAGULABLE STATE EX. PROTEIN C/S DEFICIENCY, NEPHROTIC ETC.

• CIRRHOSIS EX. UNTX INB ERROR OF MET, BILIARY ATRESIA, CONGENITAL HEPATITIS

• BUDD-CHIARI SYNDROME

• CHF EX. UNCORRECTED VALVULAR DEFECTS, PPHN

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• ANEMIA

• MOA

• RBC ABNORMALITIES & HYPERPLASIA OF THE RE SYSTEM SECOND TO DESTR OF RBC

• EXAMPLES

• SCD

• HS

• THAL

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• NEOPLASM

• MOA

• BM HYPOFUNCTION LEADS TO COMPENSATORY EXTRAMEDULLARY HEMATOPOIESIS

• EXAMPLES

• APLASTIC ANEMIA

• MYELOFIBROSIS

• LEUKEMIAS

CASE 2

C/O DR. RUTHNUM

PATIENT 2

• BACKGROUND

• PATIENT 2, 3 Y/O FEMALE

• TERMS BABY, BORN TO COCAINE-DEPENDANT MOTHER

• OTHERWISE HEALTHY

• PRODROMAL TONSILLITIS AND ON AMOX X 7 DAYS ON PRESENTATION

PATIENT 2

• RFC

• 10/16/05 - 1ST NOTED EASY BRUISING FOLLOWING BABY FELL FROM A COUCH

• BABY V. IRRITABLE AND HAVING TANTRUMS

• MOM DENIES BABY HAS ABD. PAIN

• ROS OTHERWISE NON-CONTRIBUTARY

PATIENT 2

• RFC CONT’D

• GP REFERRED PATIENT 2 TO THE RGH TO R/O HSP

PATIENT 2

• PEX

• GENERALLY PALE

• MULTIPLE BRUISES NOTED ON LIPS, BUTTOCKS, ARMS AND LEGS

• MULTIPLE PETECHIAE ON CHEST

PATIENT 2

• PEX CONT’D

• NOTABLE SPLENOMEGALY 3-4 CM BELOW COSTAL MARGIN

• ENLARGED RIGHT PREAURICULAR AND SUBMAXILLARY LN

• REST OF EXAM UNREVIELING

PATIENT 2

• QUESTION

• GIVEN THIS PRESENTATION, WHAT SHOULD YOU CONSIDER IN YOUR DDX?

PATIENT 2

• DDX

• VASCULITIS EX. HSP• LEUKEMIA• LYMPHOMA• HUS/TTP• CHILD ABUSE

PATIENT 2

• LABS• PLT 17• WBC 75.3• RBC 2.09• HGB 65• MCV 87.5• LD 1355• UREA 330• PT 14.6• MONO TEST -VE• BLASTS NOTED

PATIENT 2

• WORKING DX OF PATIENT 2 : ALL

PATIENT 2

• MANAGEMENT

• IN ANTICIPATION FOR CHEMO, BABY RECEIVED AN ECHO FOR BASELINE HEART FUNCTION AND URIC ACID LEVELS WERE NOTED TO BE WNL

• TRANSFERRED CARE TO PASQUA TO SEE ONCOLOGIST

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• THYROTOXICOSIS

• MOA

• T3/4 INDUCED LYMPHOID HYPERPLASIA

• EXAMPLES

• GRAVES DISEASE

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• INFECTION

• EXAMPLES

• MALARIA

• MONO

• HIV

• SARCOID/SLE/SYSTEMIC DZ

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• WHAT DRUGS ARE IMPLICATED IN THROMBOCYTOPENIA?

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• ABX EX. TMP-SMX : EX. UTI

• CARDIAC MEDS EX. QUINIDINE, PROCAINAMIDE

• DIURETIC MEDS (THIAZIDES) : EX. MCD

• ANTI-RHEUMATICS : EX. RF

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• DO NOT MISS HEPARIN-INDUCED THROMBOCYTOPENIA (HIT)

• CAN CONFIRM WITH IN VITRO TESTING OF HEPARIN DEPENDANT PLATELET ANTIBODIES

• REQUIRES IMMEDIATE CESSATION OF DRUG USE

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• STEP 4

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• RULE OUT ISOLATED THROMBOCYTOPENIA

• USUALLY THESE ARE INHERITED

• WILL SEE GIANT PLATELETS ON PBS

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• MAY-HEGGLIN ANOMALY : AD BLOOD D/O; SEE DOHLE BODIES IN LEKOCYTES

• BERNARD-SOULIER SYNDROME : AR BLOOD D/O; DEFICIENCY OF PLATLET GLYCOPROTEIN

• WISKOTT-ALDRICK SYNDROME : XR D/O WITH ECZEMA, LOW LATLETS AND INCREASED INFECTIONS

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• STEP 5

AN APPROACH TO THROMBOCYTOPENIA CONT’D

• CONSIDER THE DIAGNOSIS OF ITP -DIAGNOSIS OF EXCLUSION !!!

FINAL CASE - CASE 3

C/O DR. DATTA & DR. ESSALAH

PATIENT 3

• BACKGROUND

• 3 Y/O FEMALE

• EAR INFECTION 1/12 AGO

• NO RASHES, NO ABD. PAIN, NO N/V/D/C

• REST OF HX NON-CONT.

PATIENT 3

• RFC

• 10/24/05 - PERIORBITAL EDEMA, MOST NOTABLE IN AM; DECREASED U/O SINCE 10/19/05

• DENIES SORE THROAT OR RECENT HX OF URTI

PATIENT 3

• PEX

• NAD

• AFEBRILE, 130/100

• FACIAL SWELLING

PATIENT 3

• PEX CONT’D

• ABDOMINAL DISTENTION

• NO RASHES

• REST OF EXAM UNREVIELING

PATIENT 3

• DDX

• GN, LIKLEY POST-STREPTOCOCCAL

• NEPHROTIC SYNDROME

• NEPHRITIC SYNDROME

PATIENT 3

• LABS

• DECREASED PLT COUNT, HEMATURIA

• HYPERKALEMIA, HYPERPHOSPHATEMIA

• HYPOCALCEMIA

• INCREASED UREA, SLIGHT INC. IN CREAT

• DECREASED ALBUMIN

• INCREASED ESR, INCREASED CRP

• NORMOCHROMIC ANEMIA, NORMAL FE STUDIES

PATIENT 3

• LABS • GRP A STREP –VE, AGBM –VE

• ANA –VE, ASO –VE

• INCREASED 1GG/IGM/1GA

• DECREASED C3/4

• MICROALBUMIN/CREAT RATIO 820

• URINALYSIS: RBC CASTS

• U/S: NO HYDRONEPHROSIS

PATIENT 3

• WORKING DX FOR PATIENT 3 WAS GN, ETIOLOGY NYD

PATIENT 3

• MANAGEMENT

• AS WITH PATIENT 1, WHO DEVELOPED RF SECONDARY TO HUS, YOU TX THE ELECTROLYTE ABNORMALITIES, MANAGE THE FLUID STATUS AND MONITOR THE BP AND URINE INS/OUTS

PATIENT 3

• MANAGEMENT CONT’D

• TX OF HYPERKALEMIA WITH KAYEXLATE

• LASIX FOR EDEMA

• STARTED ON CCB FOR HTN

PATIENT 3

• MANAGEMENT CONT’D

• DAILY U/O, WT AND BP

• WILL R/A TODAY FOR RENAL BX

PATIENT 3

• IN KEEPING WITH TODAY’S TOPIC, WHAT CAUSED THE

THROMBOCYTOPENIA IN THIS PATIENT?

• WHAT IS THE MOST LIKLEY ETIOLOGY OF PATIENT 3’S PRESENTING

COMPLAINTS?

THROMBOCYTOPENIA

PRESENTED BY: BASIL AL-SAIGH, FMR – 1

SUPERVISORS: DR. ESSALAH

DR. RUTHNUM

DR. DATTA