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Thrombocytopenia in the UC

Mizuho Morrison, DO, Aaron Bright, MD, and Tarlan Hedayati, MD
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Thrombocytopenia, can occur due to a variety of reasons. Patients can have acute or chronic causes, and based on their underlying disease, may manifest differently. Knowing what to do based on patient's platelet count and their presentation could be lifesaving.

Pearls:

  • Thrombocytopenia occurs by one of 3 mechanisms: decreased platelet production, destruction/consumption of platelets or the production of defective platelets.

  • Decisions about dispo and transfusion vary by the number of platelets, severity of bleeding and appearance of the patient.

  • Patients with platelets < 20,000 are at high risk of severe, spontaneous bleeding and require referral to the emergency department.

  • Thrombocytopenia + anemia is concerning for either significant blood loss or the life threatening hemolytic anemia Thrombotic Thrombocytopenic Purpura.

 

CASE: A 62yo woman presents to the Urgent Care with gingival bleeding. The bleeding is spontaneous (did not start after toothbrushing) and she has never had this problem before.  No history of epistaxis. She has no headache. She has no past medical history, including von Willibrand’s disease or any other bleeding disorders. She reports a recent UTI for which she was treated with trimethoprim-sulfamethoxazole (Bactrim). She takes 81mg ASA daily.

 

She looks well, vitals are stable. She has oozing from her gums. There are no petechial or purpuric lesions.    

 

  • When patients present with a bleeding problem, it is important to quantify when and how much bleeding is occurring:

    • Is it spontaneous or precipitated by a trauma (i.e. tooth brushing)?

    • Is it every day or only occasionally?

    • How much bleeding occurs?

    • Does it stop quickly, or does it continue to ooze for several minutes or hours?

    • Is there other abnormal bleeding, i.e. vaginal or rectal bleeding?

  • Ask about contributing medications:

    • Aspirin

    • Antiplatelet medications (i.e clopidogrel (Plavix))

    • Warfarin

    • Direct oral anticoagulants

  • Examine the patient thoroughly looking for:

    • Bruises

    • Rashes

    • Petechiae/purpura

    • Evidence of bleeding elsewhere

 

THROMBOCYTOPENIA - 3 mechanisms

  • Decreased production of platelets

    • Bone marrow suppression in chronic alcohol use, cirrhosis or chemotherapy

    • Aplastic anemia

    • Malignancies

  • Destruction of platelets

    • Immune-mediated destruction - drug-induced or Idiopathic thrombocytopenic purpura (ITP)

    • Increased consumption - Disseminated intravascular coagulopathy (DIC), Thrombotic thrombocytopenic purpura (TTP)

  • Defective platelets

    • Genetic disorders (von Willebrand’s disease and many others)

    • Anti-platelet medications (including ASA and clopidogrel)

 

PRESENTATION

  • Can range from asymptomatic to critically ill and hemorrhaging

 

EVALUATION

  • In the UC, we often do not have the luxury of ordering a coagulation panel and peripheral smear to clarify the patient’s diagnosis.

  • Need at least a basic CBC

    • Platelets < 150,000 is in the range of thrombocytopenia

      • 70,000-150,000 > mild

      • 30,000-70,000 > moderate

      • <30,000 > severe

      • <20,000 > at risk for severe, spontaneous bleeding

    • Hemoglobin. If low, this could be from bleeding if there has been significant blood loss, but also could be from hemolysis. A hemolytic anemia with a thrombocytopenia, is concerning for TTP which is life-threatening.

  • There are no evidence-based recommendations for a safe platelet count.  

    • The decision about when to refer a patient to the Emergency Department varies and depends on how low the platelets are, how significant the bleeding is, and how well or sick the patient looks.  

    • A good rule of thumb is that 50,000 or below needs to be sent to the ED.  50,000-100,000 need close follow up with their PMD or a hematologist.

 

MANAGEMENT

  • Varies significantly based on the underlying etiology.

  • Who needs a transfusion?

    • Patients who require an invasive procedure (i.e. colonoscopy, endoscopy for GI bleeding, or Gyn procedure for vaginal bleeding) - transfuse at 50,000-100,00

    • Active bleeding (hematochezia, melena, hematemesis) - transfuse at 50,000

    • Minor bleeding (controlled epistaxis or gingival bleeding) or no bleeding - transfuse at 10,000-20,000

 

Differential Diagnosis of Thrombocytopenia

  • Medication-induced thrombocytopenia (Bactrim, as in our patient’s case).

  • Immune-mediated thrombocytopenia (ITP).

  • Alcohol use - causes direct bone marrow toxicity and results in a macrocytic anemia and thrombocytopenia.

  • Thrombotic thrombocytopenic purpura.

  • Hemolytic uremic syndrome - in patients with a preceding gastrointestinal distress.

  • Disseminated intravascular coagulation.

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