Difference between revisions of "Immune thrombocytopenic purpura"

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==Background==
 
==Background==
 
*Acquired autoimmune disease resulting in destruction of platelets
 
*Acquired autoimmune disease resulting in destruction of platelets
*Because circulating plts are functional, life-threatening bleeding only once plt <10K
+
*Because circulating platelets are functional, life-threatening bleeding only once platelet count <10K
*Types
+
 
**Acute
+
==Types==
***More common among younger children
+
*Acute
***Affects men/women equally
+
**More common among younger children
***Resolves in 1-2mo
+
**Affects men/women equally
**Chronic
+
**Resolves in 1-2 months
***Lasts >3mo
+
*Chronic
***More common in adults and women
+
**Lasts > 3 months
***Rarely remits spontaneously or with tx
+
**More common in adults and women
***More likely to have an ynderlying disease or autoimmune disorder (e.g. SLE)
+
**Rarely remits spontaneously or with treatment
 +
**More likely to have an underlying disease or autoimmune disorder (e.g. SLE)
  
 
==Clinical Features==
 
==Clinical Features==
 
*Petechiae
 
*Petechiae
*Epistaxis, ginigival bleeding, menorrhagia
+
*Epistaxis, gingival bleeding, menorrhagia
  
 
==Diagnosis==
 
==Diagnosis==
 
*Diagnosis of exclusion
 
*Diagnosis of exclusion
**Must differentiate from chronic ITP, which suggests an underlying disorder
+
*Must differentiate acute ITP from chronic ITP, which suggests an underlying disorder
 
*CBC shows normal cell lines except for the platelets (may have mild anemia)
 
*CBC shows normal cell lines except for the platelets (may have mild anemia)
  
==Treatment==
+
==Treatment Options==
=== Options ===
+
#'''First choice in adults:''' Corticosteroids
#Corticosteroids
+
##Prednisone 60-100 mg/d with taper after count reaches normal  
##First-line in adults  
+
##Methylprednisolone 30mg/kg/d IV x 3 days (for life-threatening bleeding)
##Prednisone 60-100 mg/d w/ taper after count reaches normal  
+
#'''First choice in children:''' Intravenous Immunoglobulin G (IVIG) 1gm/kg/d x 2 days
##Methylprednisolone 30mg/kg/d IV x3d (for life-threatening bleeding)
+
#Anti-D (RhoGAM): patient must be Rh+ for it to work
#IVIG
 
##First-line in children  
 
##1gm/kg/d x2d
 
#Anti-D (RhoGAM)  
 
##Pt must be Rh+ for it to work
 
 
#Transfusion (platelets)  
 
#Transfusion (platelets)  
 
##Indicated for life-threatening bleeding  
 
##Indicated for life-threatening bleeding  
 
##Transfuse only following first dose of methylprednisolone or IVIG  
 
##Transfuse only following first dose of methylprednisolone or IVIG  
###Holding transfusion until after first dose results in greater rise in plt count
+
###Holding transfusion until after first dose results in greater rise in platelet count
#Estrogen (uterine bleeding)
+
#Estrogen for uterine bleeding: 25mg IV x1
#25mg IV x1
 
  
===Indications===
+
==Treatment Indications==
====Adults====
+
===Adults===
#Plt >30K and asymptomatic: Usually do not require treatment
+
#Plt >30K and asymptomatic: usually do not require treatment
#Plt count <30K: Prednisone
+
#Plt count <30K: prednisone
#Plt <50K AND bleeding: Prednisone
+
#Plt <50K AND bleeding: prednisone
#Life-threatening bleeding
+
#Life-threatening bleeding: IVIG, methylprednisolone, platelet transfusion
##IVIG, methylprednisolone, platelet transfusion
 
  
====Children====
+
===Children===
#Plt count >30K: Usually do not require treatment
+
#Platelet count >30K: usually do not require treatment
#Plt count <20K + significant bleeding: IVIG
+
#Platelet count <20K + significant bleeding: IVIG
#Plt count <10K: IVIG
+
#Platelet count <10K: IVIG
#Life-threatening bleeding
+
#Life-threatening bleeding: IVIG, methylprednisolone, platelet transfusion
##IVIG, methylprednisolone, platelet transfusion
 
  
 
==Disposition==
 
==Disposition==
#Admit:
+
#'''Admit:''' platelet count <20K or significant mucous membrane bleeding
##Pts w/ plt count <20K or those who have significant mucous membrane bleeding
+
#'''Discharge:''' platelet count >20K AND asymptomatic OR only minor petechiae
#Discharge:
 
##Plt counts >20K AND asymptomatic or have only minor petechiae
 
  
 
==Complications==
 
==Complications==
#Rare; more common in elderly
+
#Rare: more common in elderly
 
##Intracerebral bleeding
 
##Intracerebral bleeding
 
##Severe GI bleeding
 
##Severe GI bleeding

Revision as of 19:00, 24 August 2013

Background

  • Acquired autoimmune disease resulting in destruction of platelets
  • Because circulating platelets are functional, life-threatening bleeding only once platelet count <10K

Types

  • Acute
    • More common among younger children
    • Affects men/women equally
    • Resolves in 1-2 months
  • Chronic
    • Lasts > 3 months
    • More common in adults and women
    • Rarely remits spontaneously or with treatment
    • More likely to have an underlying disease or autoimmune disorder (e.g. SLE)

Clinical Features

  • Petechiae
  • Epistaxis, gingival bleeding, menorrhagia

Diagnosis

  • Diagnosis of exclusion
  • Must differentiate acute ITP from chronic ITP, which suggests an underlying disorder
  • CBC shows normal cell lines except for the platelets (may have mild anemia)

Treatment Options

  1. First choice in adults: Corticosteroids
    1. Prednisone 60-100 mg/d with taper after count reaches normal
    2. Methylprednisolone 30mg/kg/d IV x 3 days (for life-threatening bleeding)
  2. First choice in children: Intravenous Immunoglobulin G (IVIG) 1gm/kg/d x 2 days
  3. Anti-D (RhoGAM): patient must be Rh+ for it to work
  4. Transfusion (platelets)
    1. Indicated for life-threatening bleeding
    2. Transfuse only following first dose of methylprednisolone or IVIG
      1. Holding transfusion until after first dose results in greater rise in platelet count
  5. Estrogen for uterine bleeding: 25mg IV x1

Treatment Indications

Adults

  1. Plt >30K and asymptomatic: usually do not require treatment
  2. Plt count <30K: prednisone
  3. Plt <50K AND bleeding: prednisone
  4. Life-threatening bleeding: IVIG, methylprednisolone, platelet transfusion

Children

  1. Platelet count >30K: usually do not require treatment
  2. Platelet count <20K + significant bleeding: IVIG
  3. Platelet count <10K: IVIG
  4. Life-threatening bleeding: IVIG, methylprednisolone, platelet transfusion

Disposition

  1. Admit: platelet count <20K or significant mucous membrane bleeding
  2. Discharge: platelet count >20K AND asymptomatic OR only minor petechiae

Complications

  1. Rare: more common in elderly
    1. Intracerebral bleeding
    2. Severe GI bleeding

See Also

ITP in Pregnancy

Source

  • Tintinalli
  • UpToDate