21 yo F with thrombocytopenia

OBJECTIVES: 

  • Work-up and evaluate a patient with thrombocytopenia

CASE:

21 yo F with history of CVID, vasculitis/arthritis, and hypercoagulability with a history of portal vein thrombosis not on any anticoagulation who presents with new petechiae and hemorrhagic blisters on her mucosal membranes that started 12 hours prior to presentation. She additionally reports nausea and 1 episode of emesis.

She has a complicated PMH (full medical history)

that includes CVID on weekly IVIg (last received yesterday), unknown arthritis/vasculitis on chronic steroids and methotrexate. She is status post splenectomy for splenomegaly as a result of portal hypertension caused by her portal vein thrombosis and is on chronic Bactrim and penicillin for prophylaxis.

In the ED, she had stable vital signs. She had multiple hemorrhagic blisters over her oral mucosa and lips but no involvement of her conjunctiva or vaginal/rectal mucosa. She has nonpalpable petechiae in her lower extremities without other evidence of bleeding or bruising. She has no palpable spleen or liver edge.

Her initial labs are notable for normal BMP, WBC of 9.5, hct of 30 (baseline from 2 years ago is 42), and plts of 6 (baseline from 2 years ago is normal). Coags are normal.

What is your differential for her thrombocytopenia? 

What additional work-up and history do you want now?


CASE CONTINUED:

What do you want to do now? 


OUTCOME: 

FINAL DIAGNOSIS: 

How is it treated? 


TAKE HOME POINTS: 


REFERENCES:

  1. Chines, DB & Blanchette, VS. 2012. “Immuno Thrombocytopenic Purpura.” NEJM. 346(13): 995-1007.
  2. Neunert, C, et al. 2011. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood.117(16): 4190-4207.
  3. George, JN & Arnold, DM. Immune thrombocytopenia (ITP) in adults: Clinical manifestations and diagnosis. In: UpToDate, Tinauer, JS (Ed), UpToDate, Waltham, MA. (Accessed on August 05, 2017.)