APPROACH TO FEBRILE THROMBOCYTOPENIA

DR.SUDESH S. PATIL DNB (INT. MEDICINE) MEDICITI HOSPITALS,

Practical Importance of Assessing Thrombocytopenia

1/3 of all Hematology Consults in a General Hospital are for thrombocytopenia 5 to 10% of all hospital patients are thrombocytopenic in the ICU the number increases to 35% Thrombocytopenic patients in the hospital suffer a twofold greater mortality rate than those who are not

Normal PhysiologyPhysiologyProduction and Number Platelets are normally made in the bone marrow from progenitor cells known as megakaryocytes. Normal platelet lifespan is 10d. Every day, 1/10 of platelet pool is replenished. Normal platelet count is between 150,000 and 450,000/mm3

Platelet Response
Platelets adhere to vessel wall, then aggregate, leading to formation of a platelet plug

Platelets provide phospholipid scaffold for thrombin generation.

ThrombocytopeniaThrombocytopeniaHow low is too low?

150,000 - 50,000: no symptoms
No treatment generally required.

50,000 - 20,000: first symptoms

Generally need to begin therapy

20,000-10,000: life-threatening
Generally requires hospitalization

<10,000: risk for spontaneous intracranial hemorrhage

Thrombocytopenia 3 broad categories of causes

Pseudothrombocytopenia Underproduction Splenic sequestration Peripheral Destruction

Pseudothrombocytopenia

Platelet clumping is of no clinical significance No increased risk of bleeding or clotting

Evaluation of Patient with Low Platelets

History Has the patient ever had a normal platelet count? Carefully review medications, including OTC meds. Antibiotics, quinine, anti-seizure medications Ask about other conditions which may be associated with low platelets Liver Disease/hepatitis Thyroid Disease - both hypo- and hyper Infections: viral, rickettsial Pregnancy Ask about other conditions which may be associated with ITP Lupus, CLL, lymphoma

Evaluation of Patient with Low Platelets

Physical Evaluate for lymphadenopathy and splenomegaly Look for stigmata of bleeding Blood blisters and oral petechiae, ie Wet Purpura
best harbinger of intracranial hemorrhage

Laboratory Data Other blood counts should be normal. Check B12 and folate levels. Look at peripheral smear to exclude pseudothrombocytopenia, also exclude TTP (especially if anemia also present.) Send coagulation screens (PT/PTT) to exclude DIC Send HIV, hepatitis serologies and TSH Consider doing a bone marrow biopsy Megakaryocytes should be present.

Thrombocytopenia
Pseudo? True?
Fragmented RBCs (Perform smear) No need to work up

TMA?
WBC, Hb PT/PTT Physical examination Splenomegaly

High WBC

Low WBC/Hb MCV-N MCV

Normal

PTT

Leukemia?

DIC? Hypersplenism?
(look for cause)

ITP?
(consider bone marrow aspiration)

Vitamin B12 deficiency? MDS?

CAUSES OF FEBRILE THROMBOCYTOPENIA

INFECTIOUS: VIRAL: Arbo,EBV,CMV,HIV,HBV,HCV.. BACTERIAL: SEPSIS,Enteric,lepto,brucella,Rickettsia PROTOZOAL: MALARIA RARELY FUNGAL Sepsis

NON INFECTIOUS: CTD: RA,SLE MALIGNANCIES: SOLID: Infilt. B.M BLOOD: AML,MULTIPLE MYELOMA. TTP,HUS

INVESTIGATIONS
CBP,ESR,PERIPHERAL SMEAR LFT,RFT,TFT,PT,APTT MP,PF VIRAL MARKERS(HIV,HBV,HCV) DENGUE,Brucella SEROLOGY WIDAL ELISA,PCR,MAT For Lepto BMA,BM Biopsy

MANAGEMENT

Platelet Transfusion
Platelet transfusions to correct thrombocytopenia transfusions:
Active bleeding Invasive procedure Prevent spontaneous bleeding (10~20 x 109/L) Contraindications: Contraindications
Heparin-induced thrombocytopenia (HIP) Thrombotic thrombocytopenic purpura (TTP)

Bleeding

massively transfused

PLT is used to treat dilutional thrombocytopenia

Wrapup
Platelet count <20
Usually requires admission R/O TTP Stop all meds, if possible Probably ITP Send HIV

Wrapup
Platelet count b/w 20-50
R/O TTP Probably requires treatment Stop all meds Send HIV

Wrapup
Platelet count b/w 50-100
Probably does not require treatment Find old CBCs to see if new or old Stop all meds, if possible Careful follow-up to see if platelet count remains stable If pt is elderly, may be MDS, o/w probably chronic ITP

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