A previously healthy 30-year-old woman is admitted to the hospital. She complains of a rash over her ankles that started 2 weeks ago and slowly spread up to her knees. The patient has no other medical problems and takes no regular medications. Her vital signs are within normal limits. Physical examination shows fine petechiae and purpura around her ankles and lower legs. There is no lymphadenopathy or hepatosplenomegaly. Laboratory results are as follows:
Peripheral blood smear shows thrombocytopenia. After reviewing the laboratory results, the admitting resident orders 6 units of random donor platelet transfusion. The following day, the platelet count is 10,000/µL.
Which of the following is the most appropriate next step in management of this patient?

Question

A previously healthy 30-year-old woman is admitted to the hospital.  She complains of a rash over her ankles that started 2 weeks ago and slowly spread up to her knees.  The patient has no other medical problems and takes no regular medications.  Her vital signs are within normal limits.  Physical examination shows fine petechiae and purpura around her ankles and lower legs.  There is no lymphadenopathy or hepatosplenomegaly.  Laboratory results are as follows:
 Peripheral blood smear shows thrombocytopenia.  After reviewing the laboratory results, the admitting resident orders 6 units of random donor platelet transfusion.  The following day, the platelet count is 10,000/µL.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf61_a2e1_8f63_a7ff6cab6f0c_MD0005_00 Immune thrombocytopenic purpura (ITP) is acute and self-limiting in children but usually becomes a chronic disorder in adults. Patients with asymptomatic mild thrombocytopenia (platelets >30,000/µL without bleeding) can generally be observed without treatment. Corticosteroids are a first-line treatment option for patients with symptoms and/or a platelet count of <30,000/µL; the majority of adults respond within 1-2 weeks. Intravenous immunoglobulin can be considered in patients who have failed or have contraindications to steroid therapy or require a more rapid increase in platelet counts. Anti-Rh(D) is an alternate treatment option in rhesus-positive non-splenectomized patients. Rituximab can be considered for patients who have failed initial treatment. Splenectomy is generally reserved for refractory cases (Choice E). (Choice B) Heparin is sometimes used very cautiously in patients with disseminated intravascular coagulation although there is little evidence of significant benefit. However, it is not effective for ITP. (Choice C) Plasma exchange is the treatment of choice for thrombotic thrombocytopenic purpura-hemolytic uremic syndrome in adults. (Choice D) ITP is due to autoantibodies that rapidly remove circulating platelets (including transfused platelets). As a result, platelet transfusions are limited to life-threatening emergencies (eg, intracranial hemorrhage). Educational objective: Patients with immune thrombocytopenia and platelets >30,000/µL without bleeding can generally be observed without treatment. Corticosteroid therapy is a first-line treatment option for immune thrombocytopenic purpura in adult patients with platelets <30,000/µL or with bleeding. References: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/21325604)

A Previously Healthy 30-Year-Old Woman Is Admitted to the Hospital