Thrombocytopenia

Pt with h/o alcohol-induced liver disease, leukemia, mechanical heart valve presents with thrombocytopenia. Reports recent tick-bite, fever/night sweats, unintended weight loss, weakness/fatigue, easy bruising. Currently undergoing chemotherapy. Recently received MMR, varicela, and influenza vaccines. Medications include NSAIDs, furosemide, ranitidine. Family h/o thrombocytopenia. Slapped-cheek rash, mucosal petechiae, lymphadenopathy, heart sounds with mechanical click, ascites, hepatosplenomegaly, jaundice on exam. No active bleeding noted.

  • Labs

    • Repeat CBC confirms thrombocytopenia

    • CMP shows elevated alkaline phosphatase and AST:ALT >2

    • Obtain blood smear, GGT, hepatitis panel, HIV ELISA

    • Consider obtaining rickettsial viral panel, bone marrow biopsy

  • Treatment

    • Stop NSAIDs, furosemide, ranitidine

    • Concern for alcohol withdrawal; start CIWA protocol

    • Platelet count < 50,000/microliter with active bleeding: Transfuse 1 apheresis unit of platelets

  • Patient’s hematologist-oncologist notified about current condition

  • Counseling

    • Pt advised to stop drinking alcohol

    • Pt counseled that if his condition is medication-induced, it will likely resolve in 7-14 days

Notes

  • Risk factors and conditions associated with thrombocytopenia

    • Viral illness including:

      • HIV

      • Hepatitis B/C

      • Parvovirus B19

      • Herpesviridae: VZV, EBV, CMV

      • Tropical: Dengue fever, malaria

    • Alcohol abuse and/or chronic liver disease

      • Mild to moderate thrombocytopenia due to decreased platelet production

      • May be associated with GI bleeding

      • Labs may show macrocytic anemia, elevated AST:ALT, and/or elevated GGT

    • Marrow suppression due to malignancy/chemotherapy: Moderate to severe thrombocytopenia that generally affects all cell lines

    • Congenital thrombocytopenia

    • Iatrogenic

      • MMR, varicella, influenza A (H1N1) vaccines

      • Destruction by mechanical heart valve

  • Treatment

    • Repeat CBC to rule out in vitro agglutination

    • Therapy based on platelet counts (per microliter)

      • > 150,000: No further workup

      • 100,000-150,000: Repeat blood work in 2-4 weeks

      • 50,000-100,000: Trend counts until > 100,000 or < 50,000 and attempt to determine etiology

      • < 50,000: Consider hematology referral/consult

Immune (idiopathic) Thrombocytopenic Purpura

  • Acquired autoimmune disorder

  • Must r/o all other etiologies (see DDX)

  • Giant platelets on peripheral smear

  • For patient >60 obtain bone marrow biopsy to r/o myelodysplastic syndrome/lymphoproliferative disorders

  • Treatment

    • Indicated if acute bleeding is present or platelets <50,000

    • Corticosteroids = first line

    • IVIG and rituximab may also be used