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One of the most common and patient hematological consultations we get is immune thrombocytopenia or ITP. Today, I want to talk about how this disorder presents, what are we looking for and how do we manage it.
Let's start with a typical case presentation. Usually would get a call from the emergency room that say a 35-year-old female who has no significant past medical history noticed a particular rash for two days and decided to come in the ER checked the account and it was 3000 they call hematology
As the person responding to this call, what am I looking for?
The first thing I am looking at in the labs is are there ANY other cell-lines that are affected such as the white blood cells or the red blood cells. If the answer is yes, this is NOT ITP
ITP is classically isolated thrombocytopenia, i.e the hemoglobin and white blood cells should be within normal limits.
the second question I am asking is—is the patient bleeding or is the patient at risk for bleeding (do they have any mucosal blisters) ?
Review the smear. Classically, you’ll see very low or absent platelets. The RBCs and WBCs are normal
If the patient is bleeding— we go all in > platelet transfusions, anti-fibrinolytics, steroids, intravenous gamma globulin
If the patient is not bleeding— and this is classical for ITP, we typically start with immunosuppression with high-dose dexamethasone or prednisone and intravenous gamma globulin to chelate out the anti-platelet antibodies that are consuming the platelets
Importantly- there is NO role for testing for anti-platelet antibodies in ITP. A positive antibody does not confirm the diagnosis and a negative antibody does not exclude the diagnosis. Therefore, I recommend saving time and money and to not order this test.
ITP smear: There one gigantic platelet in the smear below and no other! RBCs are normal
Image credit: ASH image bank
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