In the GIM clinic today, I had a middle-aged patient referred for assessment of his incidental thrombocytopenia.
My takeaway for an approach to thrombocytopenia is as follows:
- Etiology
- Decreased production of platelets
- Bone marrow suppression - e.g. methotrexate, alcohol, MDS, aplastic anemia
- Increased consumption/destruction of platelets
- Hematological - DIC, TTP, HUS
- These are particularly important to rule out
- Autoimmune - ITP (idiopathic thrombocytopenic purpura), Evan's syndrome
- Drug-induced - e.g. heparin (HIT), anti-convulsants
- Infectious - hepatitis C, HIV
- Sequestration in spleen
- Splenomegaly due to increased portal hypertension (e.g. cirrhosis)
- History
- Symptoms
- Bleeding
- Mucosal - epistaxis, gum bleeding, GU bleeding
- GI bleeding - hematemesis, BRBPR, and melena
- Bruising
- Rashes - particularly purpura and petechiae
- Risk factors
- Drug-related - e.g. heparin, anticonvulsants, antibiotics
- Malignancy, sepsis, cirrhosis
- Physical
- General
- Mucosal bleeding
- Bruising and rashes - petechiae, purpura
- Stigmata of liver disease
- Neuro:
- Mental status
- HEENT:
- lymphadenopathy
- Abdominal
- Assess for hepatosplenomegaly
- Investigations:
- CBC to monitor platelets but also assess for anemia
- Peripheral blood smear
- Consider
- DAT to rule out hemolytic anemia
- hepatitis C and HIV serologies
- Management
- Transfusion if platelets <10 or <50 for certain surgeries (in general)
- Immune suppression: IVIG +/- steroids, rituximab
- Consider splenectomy
- Treat underlying cause - e.g. discontinue heparin
My patient likely has a transient mild thrombocytopenia secondary to a viral infection or secondary to his use of anti-convulsants or PPI. I also recently found out about the importance of using a PPI for prophylaxis when using high-dose steroids.
-JT-
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