Thrombocytopenia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Introduction

Thrombocytopenia is the decreased concentration of platelets below 150,000 cells per microliter of blood.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Disseminated intravascular coagulation
• HELLP syndrome

Common Causes

• Bone marrow suppression (chemotherapy, irradiation)
• Chronic alcohol use
• Chronic liver disease
• Congenital thrombocytopenia
• Disseminated intravascular coagulation
• Hemolytic uremic syndrome
• Heparin-induced thrombocytopenia
• Immune thrombocytopenic purpura
• Infections
• Medications
• Preeclampsia
• Pregnancy
• Pseudothrombocytopenia
• Thrombotic thrombocytopenic purpura

Management

Shown below is an algorithm depicting the initial approach to thrombocytopenia.

Characterize the symptoms: ❑ Onset (acute, chronic, recurrent) ❑ Easy bruising ❑ Petechiae ❑ Rashes ❑ Melena ❑ Fevers ❑ Bleeding ❑ Headaches ❑ Abdominal pain ❑ Visual disturbances ❑ Weight loss ❑ Night sweats ❑ Bone pain Obtain a detailed history: ❑ Recent medications ❑ Pregnancy ❑ Family history ❑ Malignancy ❑ Recent infection ❑ Recent vaccinations ❑ Recent travels ❑ Recent transfusions ❑ Chronic alcohol use ❑ Recent hospitalization ❑ Recent organ transplantation ❑ Recent valve replacement surgery ❑ Dietary habits ❑ Sexual history ❑ Ingestion of quinine containing beverages

Examine the patient: ❑ Bleeding location ❑ Bleeding severity ❑ Hepatomegaly ❑ Splenomegaly ❑ Mucocutaneous bleeding ❑ Skeletal abnormalities ❑ Joint or soft tissue bleeding ❑ Rash ❑ Generalized lymphadenopathy ❑ Skin necrosis ❑ Neurologic exam

Order tests: ❑ Peripheral blood smear ❑ CBC and differential ❑ Reticulocyte count ❑ LDH ❑ LFT ❑ Renal function test ❑ Clotting screen ❑ PT ❑ aPTT ❑ Fibrinogen ❑ Haptoglobin ❑ D-dimer ❑ Request a hematology consult

❑ Order additional tests based on the results of the CBC-D and peripheral blood smear

Possible Pseudothrombocytopenia ❑ Clumped platelets

True thrombocytopenia

❑ Order platelet count on heparinized blood specimen

Isolated thrombocytopenia

Thrombocytopenia with abnormalities in other blood lineages

Consider: ITP TTP DIC

Guide your next step by specific findings

Look for: ❑ Shistocytes ❑ Spherocytes ❑ Dacrocytes ❑ Blasts Giant platelets ❑ Granulations ❑ Hypersegmented neutrophils ❑ Macrocytosis ❑ Lymphocytosis ❑ Neutropenia

Treatment of Thrombocytopenia

The treatment of thrombocytopenia is specific to the underlying cause of thrombocytopenia.

Do's

• Bone marrow biopsy should be done for patients that are older than 60 years of age to rule out myelodysplastic syndrome or lymphoproliferative disorders.
• Treatment should be considered for patients with platelet counts less than 30,000 per microliter.

Dont's

• Don't initiate cancer chemotherapy or antiviral therapy in the presence of thrombocytopenia.
• Don't start the treatment for platelet counts greater than 50,000 per microliter unless the patient is actively bleeding.
• Don't give warfarin monotherapy to an acutely bleeding patient because it may induce thrombosis.