Thrombocytopenia

1

• Thrombocytopenia
• Dr S W Bokhari
• Consultant Haematologist
• University Hospital Coventry and Warwickshire

2
Thrombocytopenia

• You are the Surgical HO asked to clerk patient on
  ward pre-operatively prior to hernia repair.
• You notice from results on CRRS that his platelet
  count one week earlier was 25. No previous
  results.
• How do you approach this problem?

3

• Repeat FBC
• Hb 13g/dL WCC 8 Neuts 2.5 Plts 28 MCV 102
• Ask for blood film to be reviewed
• Film comment confirmed thrombocytopenia, normal
• platelet morphology mild macrocytosis no other
  abnormal
• features
• Inform surgeons/theatres etc

4
Peripheral blood film
5
Platelet clumping
6
History

• 40 year old man
• Symptoms
• Bleeding history severity and duration
• Recent illness including infections esp. viral
• Patient had noticed easy bruising for previous 2
  months.
• Fit and well with no recent illness

7
Mucosal bleeding
8
Purpura
9
Past Medical History

• Infections bacterial, viral, fungal
• Autoimmune disease
• Liver disease
• Malignancy
• Occasional backpain
• Road traffic accident 5 years ago following which
  he
• received blood transfusion

10
Family History

• Congenital causes of thrombocytopenia
• Autoimmune disease
• Mother IDDM
• Sister recently diagnosed with SLE

11
Drug History

• Long list to consider!
• -immune-mediated
• -direct effect on BM or MK
• Alcohol intake
• Takes diclofenac for backpain
• 30 units alcohol per week spirits
• Smokes 15/day

12
Social History

• Occupation - ? Exposure to toxic agents
• Dietary history
• Recent travel abroad infections
• Risk factors for HIV
• Recently made redundant having previously worked
  in
• motor industry
• No recent travel abroad
• No risk factors for HIV

13
Examination

• Bleeding/bruising
• Anaemia
• Clubbing/jaundice (other features of CLD)
• Lymphadenopathy
• Signs of malignancy
• Hepatomegaly
• Splenomegaly
• Features associated with congenital causes esp.
  Fanconi
• anaemia

14

• Bruising over arms and legs
• ? Yellow sclera
• Liver palpable 3cm
• No other findings

15
Investigations

• FBC
• Pancytopenia or isolated thrombocytopenia
• MCV
• Blood film
• Confirm thrombocytopenia
• Platelet size and morphology
• Red cell fragments
• Red cell abnormalities e.g. target cells
• WBC features

16
Giant platelets
17
Red cell fragments
18
Target cells
19
Hypersegmented neutrophil
20

• Hb 13g/dL WCC 5 Neuts 2.0 Plts 28 MCV 102
• Target cells and stomatocytes

21

• Renal function
• Liver function
• B12 and folate
• Full clotting screen
• Normal renal function
• AST 160 Alk phos 170 ALT 130 Bili 60 ?GT 100
• B12 110 Folate 1.4
• PT ratio 1.6 APTT ratio 1.4 Normal fibrinogen and
  TT

22

• Autoantibody screen specific autoantibodies as
  indicated
• Antiphospholipid antibodies
• Lupus anticoagulant
• Anticardiolipin antibodies
• Autoantibodies screen negative
• Antiphospholipid antibodies positive

23

• Virology testing
• EBV, CMV, toxoplasma
• Hep B, C
• HIV
• Hepatitis C positive
• Presumed secondary to blood transfusion

24
Causes of thrombocytopenia

• Failure of production
• Increased consumption/destruction
• Abnormal pooling - splenomegaly

25
Failure of production

• Congenital
• Fanconi anaemia, TAR (thrombocytopenia with
  absent
• radii), Wiskott-Aldrich syndrome, Bernard-Soulier
  synd.,
• May-Hegglin anomaly, Alport synd. variant, Grey
  platelet
• synd.
• Acquired specific thrombocytopenia
• Infection esp. viral
• Nutritional deficiency B12/folate
• Toxic effect of drugs (more often immune) or
  alcohol

26
Failure of production

• Acquired as part of bone marrow failure
• Drugs including chemotherapy
• Radiotherapy
• Marrow infiltration malignant/non-malignant
• Aplastic anaemia

27
Bone marrow aspirate
28
Bone marrow trephine
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Increased destruction of platelets

• Immune
• Idiopathic
• ITP (acute and chronic)
• Secondary
• Autoimmune disease e.g. SLE
• Infections e.g. HIV, Hepatitis C
• Drugs e.g. heparin (HIT), quinine, quinidine,
  gold salts
• Lymphoproliferative disease e.g. CLL
• Neonatal alloimmune thrombocytopenia
• Post-transfusion purpura

30
Increased destruction of platelets

• Non-immune
• Microangiopathic haemolytic anaemia (MAHA)
• DIC
• HUS
• TTP idiopathic or 2º e.g. pregnancy,
  infection, metastatic carcinoma, drugs, BMT, AI
  disease
• Pregnancy related
• Gestational thrombocytopenia
• Preeclampsia
• HELLP

31
Management

• Few spontaneous bleeding problems if plts gt 30
• Unless
• Abnormal platelet function
• Associated coagulopathy
• In general patients need treatment if symptomatic
  or increased risk of bleeding e.g.
  peri/post-operatively, trauma, obstetric
• In general would want platelets gt 50 for minor op
  and gt80/100 for major op.
• May need to transfuse plts if count higher but
  abnormal function

32
Management

• May need bone marrow to determine whether cause
  of thrombocytopenia is failure of production or
  increased destruction
• Stop any possible implicated drugs
• In general if failure of production
• Platelet transfusions
• Treat underlying cause e.g. B12/folate
  replacement

33
Management

• In general if increased destruction
• Avoid platelet transfusions as these are often
  ineffective and can make clinical situation worse
  e.g. TTP, HIT
• Exception - DIC
• May be required if life-threatening bleeding
  e.g. ITP
• Treat underlying cause e.g. CLL
• ITP
• Immunosuppression steroids, IVIG, other
  immunosuppressive agents
• Splenectomy

34
Management

• TTP-HUS may require plasma exchange/FFP
• NAIT/PTP may require HPA1A neg plts