Thrombocytopenia

張貼日期：2018/1/8 上午 11:04:04

回覆模板：

A 70 y/o female was admitted due to 

Chronic/recent onset/acute thrombocytopenia was found, and we are consulted for further evaluation.

[Major past history]

[PE]

E4V5M6

Mouth: several oozing blood clot at oral mucosa

Abdomen: splenomegaly(-)

Skin: petechiae over lower limbs

[Platelet and Hb course]

Hb: ____  (date) -> ____  (date) -> ____  (date) -> ____  (date)

Plt: ____  (date)-> ____  (date) -> ____  (date) -> ____  (date) . Transfusion refractoriness (+/-)

[PB smear]: schistocyte(-), giant platelet(+), platelet clumping(-), spherocytes(+)

[DIC profiles]

Fibrinogen/PT/aPTT/D-dimer: 

LDH: ____  (date)

Bil-T: ____  (date)

[Infectious etiology]

HIV/HCV/H. pylori: (+)/(?)/(?)

[Medications history]

Tazocin: (Date starts) - (Date ends)

Probable mechanism of thrombocytopenia

• 1. Artifact

  2. Decreased production

  3. Increased destruction

  4. Platelet sequestration

  5. Special condition: hypothermia, hemodilution, cardiopulmonary bypass

If ITP is suspected (commonly 1 hour CCI < 10000), identify probable causes of secondary ITP:

• • Autoimmune disorder: SLE(?), Antiphospholipid syndrome(?)

  • Infections: HIV(?), HCV(?), Helicobacter pylori(?)

  • Drugs: heparin(-), antibiotics(penicillin, linezolid, rifampin, sulfonamides, vancomycin), NSAIDs(-), Platelet inhibitors(-), food(walnuts, milk, cranberry juice), beverage, herbs

  • Vaccines: measles(-), mumps(-), rubella(-), varicella(-)

  • Lymphoproliferative disorder: not evident at present

[Impression]

1. Severe thrombocytopenia, suspect immune thrombocytopenia(ITP)

2. HTN

[Suggestions]

1. Follow CBC QOD and component therapy with "減白加電血品" Plt 12u stat to keep platelet number > 10 k/uL.

2. 請血液室做PB smear

3. Check following blood exams "1hr after" platelet transfusion

CBC, Bil-T, LDH, IgG, direct Coomb's test (profile of Coombs’ poly-specific and monospecific DAT)/indirect Coomb's test, PT/aPTT, D-dimer, fibrinogen

4. Calculate 1 hr CCI:

   Corrected count increment(CCI) = [post-transfusion platelet increment(/uL) x BSA (m2)] x 10^11/ number of platelets transfused

   (each single donor platelet 12u = 3 x 10^11 platelets)

   If 1 hr CCI < 10000, platelet transfusion refractoriness is confirmed (immune/non-immune factors related high consumption). 

   Prepare HLA-matched irradiated platelet

5. 根據臨床狀況及PB smear(isolated thrombocytopenia with giant platelet)判斷像不像ITP，若像ITP則加驗下列：

HIV combo test, HBsAg, anti-HCV, 碳13 尿素呼氣檢查(cash)

Anti-ENA screen, anti-dsDNA, C3/C4, ANA, anti-cardiolipin IgG/IgM, anti-beta2 glycoprotein 1 IgG/IgM, DRVVT

(anti-phospholipid IgG/IgM, RF, Anti-TPO)

Plateletantibody (血小板HPA抗體及HLA Class I抗體篩檢: optional) 

6. Arrange CxR to exclude pulmonary tuberculosis & mediastinal lymphadenopathy.

7. Arrange abdominal echo to exclude splenic sequestration of platelets. (optional)

Treatment for ITP

1. Give IVIG for life threatening bleeding

   - Vena 1 amp before IVIG infusion.

   - IVIG (1g/kg) QD x 2 days, 第一瓶run 50ml/hr, 第二瓶run 100ml/hr, 若無不適，可上調流速至200ml/hr 

2. Give dexamethasone 40mg PO QD x 4 days

3. Inform risk of rare severe bleeding (such as ICH or GI bleeding ~ 5%)

4. BM study (A+B+C) is suggested in elderly(> 60 y/o) ITP patient to exclude BM neoplasm/MDS.