Written by: John Bass, MD
CC: ‘Cough and Malaise’
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
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.
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
Mechanical (TTP; HUS; DIC)
Immunologic (Antiphospholipid Syndrome/SLE; Sepsis; Post-Infection)
Infection (CMV; HIV; Varicella Zoster)
Drugs/Medications (Heparin; Gold Salts; Sulfa Drugs; Quinine; Chronic EtOH)
Nutritional Deficiency (B12; Folate)
Extracorporeal Membrane Oxygenation (ECMO)
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.
– Peripheral Smear
– Coagulation Panel (PT/PTT/INR/Fibrinogen)
If clinically indicated:
– Urine Analysis
– HIT Panel/Serotonin Assay
B12 and Folate Levels
– 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
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.
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