Written by: John Bass, MD

CC: ‘Cough and Malaise’

HPI: 

32M presenting with 3 days of gradual onset, non-productive intermittent cough and sore throat, and general fatigue.  Known sick contacts with similar constellation of symptoms.  Denies recent travel and immunizations up to date, including annual influenza vaccine.  PO tolerant of fluids, and symptoms adequately controlled with throat lozenges and Tylenol as needed — presents to Emergency Department for evaluation of atraumatic bruising to bilateral lower extremities on morning of presentation. Endorses subjective fever; denies nausea or vomiting, ear pain or vision changes, epistaxis, chest pain or shortness of breath, abdominal pain, or focal neuromuscular deficits.

VS: HR 80 BP 130/75 RR 16 SpO2 98% Temp 99.6F

Denies any PMHx, PSHx

Denies current medication use

No known drug allergies

Denies Tobacco or Recreational Drug Use; Social EtOH

PE:

GEN: WD WN male in NAD

HEENT: Normocephalic and atraumatic; EOMI without conjunctival injection. TMs without bulging or fluid level. Dentition appropriate. Symmetric grade 1 tonsils without exudate.

CV: S1 S2 RRR no MRG

Pulm: CTAB without wheezes or crackles

Abd: Soft NT ND with BT present

Neuro: CN III-XII grossly intact; purposeful movement of UE and LE bilaterally without asymmetry or deformity

Psych: alert, appropriate and conversational

Derm: Diffuse, well-circumscribed, non-blanching petechiae over lower extremity without clear anatomic or vascular distribution. Scant petechiae over anterior abdomen and chest. Superficial linear abrasion with extensive bruising over R elbow. Palatal petechiae.

petechiae

What is the differential diagnosis for this presentation?

What initial labs/imaging/studies would you order?

How best do you manage this patient?

Causes and Differential

Increased Destruction

Mechanical (TTP; HUS; DIC)

Immunologic (Antiphospholipid Syndrome/SLE; Sepsis; Post-Infection)

Decreased Production

Infection (CMV; HIV; Varicella Zoster)

Drugs/Medications (Heparin; Gold Salts; Sulfa Drugs; Quinine; Chronic EtOH)

Nutritional Deficiency (B12; Folate)

Splenic Sequestration

Dilutional

Massive Transfusion

Extracorporeal Membrane Oxygenation (ECMO)

Diagnosis

In the setting of the patient’s recent viral infection, and without any medication history or significant medical co-morbidities, an infectious thrombocytopenia is the most likely explanation for the patient’s malaise and progressive, atraumatic distribution of petechiae.

Testing

– CBC

– Peripheral Smear

– Coagulation Panel (PT/PTT/INR/Fibrinogen)

If clinically indicated:

– Urine Analysis

– LFTs

– HIT Panel/Serotonin Assay

B12 and Folate Levels

Management

– Treat the underlying cause, or remove the offending agent, if identifiable

– Pharmacologic intervention is usually reserved for rare cases (platelets < 50,000) or active bleeding.

Corticosteroids are the mainstay of initial therapy:

– Prednisone 1mg/kg PO QD for 21 days, followed by a taper

– Methylprednisolone 30mg/kg/QD for 3 days

– In clinical studies, extended treatment with Prednisone achieved prolonged time to relapse

Steroid therapy may be supplemented by the addition of IVIG if a rapid increase in platelets is desired:

– Believed to accelerate the clearance of anti-platelet antibodies

– IVIG 1gm/kg continuous infusion over 24 hours

Platelet transfusion should be reserved for potentially life threatening presentations of ITP, and preferably withheld until after the aforementioned therapies have been initiated

– Transfuse to goal platelet level of 50,000, or as per recommendations of Hematology/Oncology

Our Patient

Initial lab work was notable for platelets of 2.  Patient was initiated on high dose steroid therapy, and subsequently transfused 1u platelets, and was admitted in stable condition for continued management and surveillance.

References

Gauer et al. ‘Thrombocytopenia’ American Family Physician. Mar 2012; 85(6): 612-622

Neunert et al. ‘The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia’ Blood: April 2011. 117(16): 4190-4207

Santern S, Hemphill R. ‘Acquired Bleeding Disorders’ Tintinalli’s Emergency Medicine.  Seventh Edition; 2011. 1465-1466

Spahr JE, Rodgers GM. ‘Treatment of immune-mediated thrombocytopenia purpura with concurrent intravenous immunoglobulin and platelet transfusion: a retrospective review of 40 patients’ American Journal of Hematology. Feb 2008; 83(2): 122-5

Advertisements