A 28-year-old woman comes to the physician because of a low platelet count incidentally discovered on routine blood work. She was recently seen by a psychiatrist for depression. She admits to depressed mood, easy fatigability, insomnia, and feelings of worthlessness for the past 6 months. She denies any history of bleeding problems. She does not take any medications, including herbal products or dietary supplements. She denies recent travel, vaccinations, or infections. She does not use tobacco, alcohol, or illicit drugs. She is not currently sexually active and denies ever being pregnant. There is no family history of bleeding disorders or cancer.
Her vital signs are within normal limits. Complete physical examination is unremarkable.
Laboratory results are as follows:

Peripheral blood smear shows thrombocytopenia, giant platelets, and an absence of platelet clumping. Red and white blood cell morphology is within normal limits.
Testing for HIV is negative.
Which of the following is the most appropriate next step in management for her thrombocytopenia?

Question

A 28-year-old woman comes to the physician because of a low platelet count incidentally discovered on routine blood work.  She was recently seen by a psychiatrist for depression.  She admits to depressed mood, easy fatigability, insomnia, and feelings of worthlessness for the past 6 months.  She denies any history of bleeding problems.  She does not take any medications, including herbal products or dietary supplements.  She denies recent travel, vaccinations, or infections.  She does not use tobacco, alcohol, or illicit drugs.  She is not currently sexually active and denies ever being pregnant.  There is no family history of bleeding disorders or cancer.
Her vital signs are within normal limits.  Complete physical examination is unremarkable.
Laboratory results are as follows:

Peripheral blood smear shows thrombocytopenia, giant platelets, and an absence of platelet clumping.  Red and white blood cell morphology is within normal limits.
Testing for HIV is negative.
Which of the following is the most appropriate next step in management for her thrombocytopenia?

Quizplus · Accepted Answer

11ec193a_982c_c0da_853d_fbeb344dc430_MD0002_00 This young woman has an incidental finding of moderate thrombocytopenia on routine blood count. Her history, physical examination, and laboratory studies do not suggest secondary causes of thrombocytopenia. This patient's absence of platelet clumping and giant platelets on peripheral blood smear suggests a young platelet population with increased turnover. A presumptive diagnosis of immune thrombocytopenic purpura (ITP) should be made at this point. Other than the history, physical examination, complete blood count, and examination of the blood smear, the only additional tests recommended in patients with presumptive ITP include HIV and HCV testing (if risk factors present), as treatment of these underlying diseases may alter the course of secondary ITP. Bone marrow aspiration is recommended in patients > 60 years of age to rule out myelodysplastic syndromes (Choice B). Treatment goals for ITP include maintaining a safe platelet count to prevent major bleeding rather than normalizing the platelet count. The majority of patients with mild to moderate asymptomatic thrombocytopenia (> 30,000 cells/µL) will have a stable and benign course and do not require treatment. Patients with severe thrombocytopenia (< 30,000 cells/µL) are at risk for future bleeding and require initial treatment with high-dose oral corticosteroids (1 mg/kg), even if they are asymptomatic (Choice C). Intravenous immunoglobulin (IVIG) may be used alone if corticosteroids are contraindicated, or in conjunction with corticosteroids in cases requiring a more rapid increase in platelet count. Splenectomy is recommended in patients refractory to corticosteroids or for those who require ongoing corticosteroids to maintain an adequate platelet count (Choice E). Rituximab is an alternative for patients who are either poor surgical candidates or for those who refuse surgery. Thrombopoiesis-stimulating agents (e.g., romiplostim, eltrombopag) are third line treatments for splenectomized adults who are refractory to other treatments. (Choice A) Current guidelines do not recommend anti-platelet antibody testing for diagnosing or managing ITP. Educational objective: Immune thrombocytopenic purpura (ITP) is presumed when the patient's history (e.g., drug exposure), physical examination, complete blood count, and peripheral blood smear examination do not suggest other etiologies for isolated thrombocytopenia. Bone marrow aspiration is indicated in patients > age 60 to rule out myelodysplastic syndromes. Patients with mild to moderate asymptomatic thrombocytopenia (> 30,000 cells/µL) should not be treated, since the majority of these patients will have a stable and benign course. __________ References: International consensus report on the investigation and management of primary immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/19846889) The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/21325604)

A 28-Year-Old Woman Comes to the Physician Because of a Low