IMMUNE THROMBOCYTOPENIC PURPURA
ABSTRACT
Immune thrombocytopenic purpura (ITP), also known as
idiopathic thrombocytopenic purpura is thought to be due to
autoimmune disease. An abnormal autoantibody (immunoglobulin G)
binds to the platelet membrane, causing removal by the spleen. If left
untreated it could lead to bleeding and possibly death (Psaila, 2007).
It is a rare pathology with an incidence of 3.25 cases per 100,000.
Typically occurring in middle-aged women but risk increases with age.
Physical exam is usually normal but pectechaie may be present on
lower extremities and/or mucosal membranes. A complete blood
count and peripheral smear show isolated thrombocytopenia.
Diagnosis is made by exclusion of secondary causes of ITP.
Treatment is based on platelet count and presence of bleeding
symptoms. Therapies usually involve combinations of steroids, IV
immunoglobin, platelet transfusion and splenectomy (Cines, 2009).
CLINICAL PRESENTATION
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CC: Bruising easily x 3 months
HPI: 21yo female states she had been bruising very easily for
the past 3 months. Noticed small purple/red bruises located
mostly on the arms and legs. The bruising frequency has
progressively increased. Minor bumps/pressure form bruises
when they had not before. Does not notice anything that
alleviates or any other associated sx. Up until this point she
had refused to have blood work done as she “hates needles”
but now is willing.
ROS:
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Denies fever, chills, fatigue, anorexia, weight loss, GI bleeding,
lymphadenopathy, recurrent infxns, dyspnea, rashes, changes in
vision, N/V/D, arthralgia, LE edema and she denied domestic
abuse three times during the visit.
CLINICAL PRESENTATION CONT…
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PMHx:
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FHx:
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Maternal grandmother - DM II
Maternal Grandfather - CAD
Paternal grandmother - HTN
SHx: Single mother, currently unemployed. Tobacco 1 PPD x 5 yrs and
drinks 1-2 beers/mo. Denies IV drug use.
Meds:
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Asthma, anxiety, bipolar disorder, high risk sexual behavior, depression,
allergic rhinitis, low-grade squamous intraepithelial lesion
Mirena 20 ug/24h IUD
Loratadine 10mg PO qD
Allergies: No Known Drug Allergies
PHYSICAL EXAM
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Vitals: T: 98.4⁰F, BP:100/64, HR:96, R: 16, Ht: 5' 2", Wt: 159 lb 6.4 oz, BMI: 29.15 (kg/m^2).
GEN: 21yo caucasian female who is alert, healthy, in no distress, well nourished and well developed.
SKIN: Bruises of the arms, legs and both breasts in varying stages of healing. +Black/blue bruises of
right upper arm; +Yellow bruise of posterior upper right arm; +Green bruise of anterior left shin.
Breasts: +yellow bruising of breasts bilaterally.
HEAD: Normocephalic, equal hair distribution, face is symmetric. TMJ is nontender & without crepitus.
EYES: PERRLA, EOM intact, Conjunctiva are pink and non-injected, sclera clear.
EARS: Tragus and helix is non-tender on palpation. Right and left tympanic membranes are pearly
gray, cone of light and handle of malleus visualized. No discharge or bleeding of canals noted.
NOSE: Bridge and naris patent without gross deformities. No pressure in maxillary or frontal sinuses.
Mucosa membranes are pink and moist.
OROPHARYNX: Buccal mucosa is pink and moist, most teeth are present with very
poor dentition, gums healthy without bleeding. No external ulcers or fissures of
lips, tonsillar enlargement.
NECK: supple with no lymphadenopathy or JVD
LYMPHATICS: no palpable lymphadenopathy
LUNGS: clear to auscultation.
HEART: regular rate & rhythm. No murmurs, gallops or rubs.
ABDOMEN: Active BS, abdomen soft, non-tender and no masses or organomegaly
Musculoskeletal: No joint edema, erythema, atrophy or boney deformity.
Full active ROM of upper and lower extremities without crepitus.
NEURO: Gait normal, Sensory/Motor grossly intact.
DIFERRENTIAL DIAGNOSIS
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Immune thrombocytopenic
purpura
Systemic lupus
erythematosus
Chronic lymphocytic
leukemia
Non-hodgkins lymphoma
Ethanol toxicity
HIV or H. pylori infection
Heparin
Blood transfusion
Sepsis
Hemolytic uremic syndrome
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Thrombotic thrombocytopenic
purpura
Myelodysplastic syndromes
Disseminated intravascular
coagulation (DIC)
Pseudothrombocytopenia
Gestational
thrombocytopenia/ Severe
pre-eclampsia
Drug-induced (quinine or
sulfamides)
Hypersplenism
LABORATORY & OTHER DIAGNOSTIC FINDINGS
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Initial Labs: ANA, Platlet Ab direct, Platlet Ab
indirect, Factor VIII, aPTT, PT/INR, CBC
 Platelets
6,000 K/uL
ASSESSMENT
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Immune Thrombocytopenic Purpura
Initial Treatment:
 prednisone 60mg PO qD
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Adults: 1-2mg/kg/day, taper dose gradually once platelet
count has reached plateau.
Stop anti-platelets (i.e. aspirin)
Refer to Hematology
CLINICAL COURSE
400,000
350,000
300,000
Platlet Count
250,000
200,000
150,000
100,000
50,000
0
25-Jan
25-Feb
25-Mar
25-Apr
25-May
Time
25-Jun
25-Jul
25-Aug
25-Sep
CLINICAL COURSE
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Treatment Now: Laparoscopic Splenectomy
 BUT
FIRST!! vaccinate for encapsulated organisms
at least 2 weeks prior to splenectomy.
 influenza,
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meningococcal, pneumococcal and hib
Imaging : Abdominal CT w/ no IV contrast
 IMPRESSION:
1. Unremarkable appearance of the spleen.
2. Cholelithiasis.
PATHOPHYSIOLOGY
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Abnormal autoantibody (immunoglobulin G) binds to the platelet membrane,
causing removal by the spleen. Although ITP is mostly asymptomatic if left
untreated it could lead to bleeding and possibly death.
Low platelet count <100,000/mm3
Epidemiology: Typically affects middle-aged women.
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2 clinical presentations:
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Acute ITP: Preceding viral infection; resolves spontaneously within 3 mo (90% of
pediatrics).
Chronic ITP: insidious onset of easy bruising/minor bleeding over a few months,
no antecedent infection, and duration >6 months (Adults).
Intracranial hemorrhage is the most frequent cause of death, occurring in
1-2% of patients diagnosed.
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Children: 2-5 years; Adults: 20-50 years. >>>> Risk increases with age <<<<
Children: males = females; Adults: females>males (3:1)
40% of diagnoses are children <10 years of age
Spontaneous remission: >80% in children and <20% in adults
Spontaneous bleeding: platelet count < 20,000/mm3 (20x109/L)
Physical exam: Often normal but pectechaie may be present on lower
extremities and/or mucosal membranes.
REFERENCES
Cines, D.B. (2009). The ITP syndrome:
pathogenic and clinical diversity. Blood,
26(113), 6511-21.
 Psaila, B. (2007). Immune thrombocytic
purpura. Hematol Oncol Clin North America,
21(4), 743-59.
 Scully, C. (2009). Aspects of human disease.
Dental Update, 7(36), 449.
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