Immune thrombocytopenic purpura

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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

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

Treatment Indications

Adults

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

Children

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

Disposition

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

Complications

  • Rare: more common in elderly
    • Intracerebral bleeding
    • Severe GI bleeding

See Also

References