Thrombocytopenia

how to proceed for a patients of thrombocytopenia

1. Approach to Thrombocytopenia PRESENTED BY:Dr Sachin Giri Moderator:Dr Nikhil Gupta Assistant Professor

2. Definitions Stages of platelets Developement Causes Approach to Thrombocytopenic Patient Diagnosis Treatment

3. T hrombocytopenia is defined as an count less than 150000/mm₃ Pseudothrombocytopenia –Blood collected in EDTA tube leads to platelets clumping due to the presence of antibodies usually IgG but also IgM IgA Definition.

4. Stages of Platelets Development

5. Pathogenesis of Thrombocytopenia can be divided into the following categories Decreased production. Peripheral destruction. Peripheral sequesrtation

6. Decreased Production Hematologic malignancies Aplastic anemia Myelodysplasia Drugs: chemotherapy, alcohol Radiation HIV Hereditary thrombocytopenias Metastatic cancer to bone marrow Causes of Thrombocytopenia

7. Immune ITP HIT Drug-induced antibodies HIV post transfusion purpura Connective tissue diseases Nonimmune DIC Sepsis TTP-HUS Kasabach Merrit syndrome Sequestrations Hypersplenism Increased Destruction

8. Histoty usually asymptomatic Presence of petechiae, ecchymoses Mucocutaneous bleeding Purpura Rarely central nervous system bleeding retinal hemorrhages Approach to Thrombocytopenia

9. History of… Recent Infections Malignancies Pregnancy status in premenopausal woman Recent medications Vaccinations Recent travels Recent transfusions Recent organ transplantation Family history of thrombocytopenia Autoimmune disorders

10. presence of petechiae ecchymosis in the skin, wet purpura in mucous membranes Splenomegaly The presence of retinal hemorrhage on ocular fundus examination is a predictor of CNS hemorrhage Examination

11. Complete blood counts Peripheral blood smear D-dimer Serum LDH Bone marrow examinations HIV ESR hsCRP Investigations

12. Due to the presence of naturally occurring antibodies that cross-react with the drug bound to the platelet. The thrombocytopenia occurs after a period of initial exposure of 21 days Resolves in 7–10 days after drug withdrawal. Abciximab exposure causes thrombocytopenia within 24 h of initial exposure. Drug induced thrombocytopenia

13. Penicillin Phenytoin Piperacillin Abciximab NSAIDs Amiodarone Amlodipine Ampicillin Carbamazepine Ceftriaxone Cephamandole Ciprofloxacin Diazepam Eptifibatide Furosemide Vancomycin Drug-Induced Thrombocytopenia

14. The thrombocytopenia is not usually severe, rarely <20,000/ μL . Heparin-induced thrombocytopenia (HIT) is not associated with bleeding, it increases the risk of thrombosis. Antibodies to complex of platelet factor 4 and heparin HIT after exposure to heparin for 5–14 days. Heparin-Induced Thrombocytopenia

15. Diagnosis by 4T scoring system-

16. HIT (anti-heparin/PF4) antibodies can be detected using two types of assays. The most widely available is an enzyme-linked immunoassay (ELISA). The other assay is a platelet activation assay, most commonly the serotonin release assay, LABORATORY TESTING FOR HIT

17. Direct thrombin inhibitor (DTI) - Argatroban -Fondaparinux Xa Inhibitor-Danaparoid Warfarin therapy. Treatment

18. Immune thrombocytopenic purpura (ITP); is an acquired disorder It is immune-mediated destruction of platelets and inhibition of platelet release from the megakaryocyte. In children, it is usually an acute disease. In adults, it is a more chronic disease. Secondary ITP if it is associated with an underlying disorder; autoimmune disorders, particularly systemic lupus erythematosus (SLE), infections, such as HIV and hepatitis C. Immune Thrombocytopenic Purpura

19. ITP is characterized by mucocutaneous bleeding and a low, often very low platelet count, with an otherwise normal peripheral blood cells and smear. Patients usually present either with ecchymoses and petechiae. Mucocutaneous bleeding may be present. Rarely, life-threatening, including central nervous system bleeding can occur. retinal hemorrhages

20. prednisone at 1 mg/kg, Anti Rh0(D) immune globulin at 50–75 μg /kg, Monitoring patients for 8 h after infusion Intravenous gamma globulin ( IVIgG ) splenectomy Eltrombopag is FDA approved for use in children over 1 year of age. Romiplostim is not yet FDA approved in children but a randomized trial supports efficacy. Immunosuppressive drugs- mycophenolate mofetil dapsone. Treatment

21. TTP is related to a deficiency or antibodies to the metalloprotease ADAMTS13, which cleaves VWF. ADAMTS13 activity levels of <10% are more clearly associated with antibody-mediated TTP. Idiopathic TTP appears to be more common in women than in men. Thrombotic thrombocytopenic purpura

22. Thrombotic Thrombocytopenic Purpura

23. plasma exchange It decreases mortality from 85–100% to 10–30%. Treatment

24. HUS is a syndrome characterized Acute renal failure Microangiopathic hemolytic anemia, Thrombocytopenia. Escherichia coli O157:H7 is the most frequent causative agent Atypical HUS ( aHUS ) is usually due to genetic defects that result in chronic complement activation or antibodies directed against complement regulatory proteins. Hemolytic -Uremic Syndrome

25. Indications of platelets tranfusion 10,000/ uL - prophylactic transfusion 20,000/ uL - in the presence of bleeding, fever, infection, platelet function defect, or coagulopathy 50,000/ uL - prior to minor procedures, in actively anticoagulated patients or in the presence of active bleeding 75,000/ uL - prior to general surgery 100,000/ uL - prior to neurologic or ophthalmologic surgery Treatment

26. Random donor platelet Single donor platelet Types of Platelet Product

27. Thrombocytopenia if platletes <150000/ul then Pseudothrombocytopenia should be ruled out Proper history taking and examination for finding out of different causes Peripheral blood smear to find out causes Indications of platelets transfusion <10000/ul Take home masseges

28. Harissons 20 th Wintrobes clinical hematology References