THROMBOCYTOPENIA

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THROMBOCYTOPENIA

• PRESENTED BY BASIL AL-SAIGH, FMR 1
• SUPERVISORS DR. ESSALAH
• DR. RUTHNUM
• DR. DATTA

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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

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AN APPROACH TO THROMBOCYTOPENIA (5 STEPS)
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AN APPROACH TO THROMBOCYTOPENIA

• HOW TO INTERPRET AN ABNORMAL COMPLETE BLOOD
  COUNT
• MAYO CLINIC PROCEEDINGS JULY 2005 80(7)923-936
• WWW.MAYOCLINICPROCEEDINGS.COM

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AN APPROACH TO THROMBOCYTOPENIA CONTD

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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• STEP 1

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• 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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• STEP 2

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• R/O HUS/TTP/DIC
• REASON THERE IS AN URGENCY FOR SPECIFIC THERAPY
  IN THESE DISORDERS

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AN APPROACH TO THROMBOCYTOPENIA CONTD

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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• CBC PBS (ANEMIA SCHISTOCYETES)
• SERUM HAPTOGLOBIN (DECREASED)
• SERUM LDH (INCREASED)
• SERUM CREATININE (INCREASED)
• COAGULATION TESTS (EXCLUDE DIC)

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CASE 1

• C/O DR. ESSALAH

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PATIENT 1

• BACKGROUND
• PATIENT 1
• 10 Y/O MALE, OTHERWISE HEALTHY
• NON-CONTRIBUTING PMHX, PSHX OR FHX AND NKDA

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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

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PATIENT 1

• RFC CONTD
• 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

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PATIENT 1

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

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PATIENT 1

• DDX
• PRE-RENAL FAILURE SEC. TO VOMITTING AND
  DIARRHEA
• RENAL FAILURE
• POST-RENAL FAILURE BILATERAL URETERAL
  COMPROMISE IN SURGERY

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PATIENT 1

• DDX CONTD
• 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

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PATIENT 1

• DDX CONTD
• 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)

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PATIENT 1

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

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PATIENT 1

• VIRAL STUDIES
• VEROTOXIN
• SHIG/SALM/C. DIFF/ GP. A STREP -

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PATIENT 1

• 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 _at_ HOME NO KIDS
  INFECTIVE DAD ENGINEER
• DIET BALANCED DIET EATS BURGERS OCC. _at_
  FRIENDS HOUSE LAST ATE STEAK/BURGERS FEW DYS
  BEFORE ADMISSION AND USED MICROWAVE TOO COOK ITIN

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PATIENT 1

• WORKING DX OF PATIENT 1 HUS

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PATIENT 1

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

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PATIENT 1

• 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

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PATIENT 1

• MANAGEMENT CONTD
• 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

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PATIENT 1

• MANAGEMENT CONTD
• SCREEN FOR LIVER, PANCREATIC DYSFUNCTION
• MONITOR FOR PLATELET COUNT, RENAL FUNCTION

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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

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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

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PATIENT 1

• D/C HOME 10/20/05

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• STEP 3

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• CONSIDER HYPERSPLENISM
• CONSIDER DRUG-INDUCED THROMBOCYTOPENIA

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• WHAT PEDIATRIC CONDITIONS CAUSE HYPERSPLENISM?

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• BANTIS

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• 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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• ANEMIA
• MOA
• RBC ABNORMALITIES HYPERPLASIA OF THE RE SYSTEM
  SECOND TO DESTR OF RBC
• EXAMPLES
• SCD
• HS
• THAL

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• NEOPLASM
• MOA
• BM HYPOFUNCTION LEADS TO COMPENSATORY
  EXTRAMEDULLARY HEMATOPOIESIS
• EXAMPLES
• APLASTIC ANEMIA
• MYELOFIBROSIS
• LEUKEMIAS

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CASE 2

• C/O DR. RUTHNUM

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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

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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

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PATIENT 2

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

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PATIENT 2

• PEX
• GENERALLY PALE
• MULTIPLE BRUISES NOTED ON LIPS, BUTTOCKS, ARMS
  AND LEGS
• MULTIPLE PETECHIAE ON CHEST

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PATIENT 2

• PEX CONTD
• NOTABLE SPLENOMEGALY 3-4 CM BELOW COSTAL MARGIN
• ENLARGED RIGHT PREAURICULAR AND SUBMAXILLARY LN
• REST OF EXAM UNREVIELING

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PATIENT 2

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

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PATIENT 2

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

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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

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PATIENT 2

• WORKING DX OF PATIENT 2 ALL

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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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• THYROTOXICOSIS
• MOA
• T3/4 INDUCED LYMPHOID HYPERPLASIA
• EXAMPLES
• GRAVES DISEASE

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• INFECTION
• EXAMPLES
• MALARIA
• MONO
• HIV
• SARCOID/SLE/SYSTEMIC DZ

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• WHAT DRUGS ARE IMPLICATED IN THROMBOCYTOPENIA?

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• ABX EX. TMP-SMX EX. UTI
• CARDIAC MEDS EX. QUINIDINE, PROCAINAMIDE
• DIURETIC MEDS (THIAZIDES) EX. MCD
• ANTI-RHEUMATICS EX. RF

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• DO NOT MISS HEPARIN-INDUCED THROMBOCYTOPENIA
  (HIT)
• CAN CONFIRM WITH IN VITRO TESTING OF HEPARIN
  DEPENDANT PLATELET ANTIBODIES
• REQUIRES IMMEDIATE CESSATION OF DRUG USE

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• STEP 4

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• RULE OUT ISOLATED THROMBOCYTOPENIA
• USUALLY THESE ARE INHERITED
• WILL SEE GIANT PLATELETS ON PBS

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• 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

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AN APPROACH TO THROMBOCYTOPENIA CONTD

• STEP 5

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AN APPROACH TO THROMBOCYTOPENIA CONTD

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

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FINAL CASE - CASE 3

• C/O DR. DATTA DR. ESSALAH

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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.

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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

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PATIENT 3

• PEX
• NAD
• AFEBRILE, 130/100
• FACIAL SWELLING

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PATIENT 3

• PEX CONTD
• ABDOMINAL DISTENTION
• NO RASHES
• REST OF EXAM UNREVIELING

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PATIENT 3

• DDX
• GN, LIKLEY POST-STREPTOCOCCAL
• NEPHROTIC SYNDROME
• NEPHRITIC SYNDROME

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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

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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

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PATIENT 3

• WORKING DX FOR PATIENT 3 WAS GN, ETIOLOGY NYD

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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

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PATIENT 3

• MANAGEMENT CONTD
• TX OF HYPERKALEMIA WITH KAYEXLATE
• LASIX FOR EDEMA
• STARTED ON CCB FOR HTN

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PATIENT 3

• MANAGEMENT CONTD
• DAILY U/O, WT AND BP
• WILL R/A TODAY FOR RENAL BX

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PATIENT 3

• IN KEEPING WITH TODAYS TOPIC, WHAT CAUSED THE
  THROMBOCYTOPENIA IN THIS PATIENT?
• WHAT IS THE MOST LIKLEY ETIOLOGY OF PATIENT 3S
  PRESENTING COMPLAINTS?

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THROMBOCYTOPENIA

• PRESENTED BY BASIL AL-SAIGH, FMR 1
• SUPERVISORS DR. ESSALAH
• DR. RUTHNUM
• DR. DATTA