RXGLGQ·WNQRZDERXWSODWHOHWV -...
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All that you didn’t know about platelets !
Dr. M.B. Agarwal, MD, MNAMS
Head, Dept of Haematology
Bombay Hospital Institute of Medical Sciences, Mumbai
CME, Vadodara, Sunday, 27th December 2015
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Spurious thrombocytopenia
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Spurious thrombocytopenia
• Harris (Bengal) syndrome
• EDTA induced platelet agglutination
• Partially clotted blood
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Thrombocytopenia : Different shades
Severity Platelet count (x 109/L) Prevalence (%)
Normal 150 - 400
Inconsequential 100 - 150 40
Mild 75 - 100 30
Moderate 30 - 75 20
Severe < 30 10
Littlewood TJ et al. Br J Haematol. 2015;93:460-463
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Thrombocytopenia : Mechanism
Production Marrow disorders
Liver disorders
Destruction
Infections, sepsis, DIC
Drugs including heparin
Immune-mediated ( ITP )
Sequestration Hypersplenism
Dilution Massive transfusion
Gestational thrombocytopenia
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Infection induced thrombocytopenia
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Infection induced thrombocytopenia
Virus
Dengue, Hanta
CMV, EBV, HCV
HIV - to remember
Bacteria Meningococcemia
Parasites Malaria
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Drug induced thrombocytopenia
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Drugs
Production Chemotherapy
Radiotherapy
Anti-folates
Others
Destruction Heparin
Rifampicin
Quinine
Na-valproate
Others
Warkentin TE et al. Annu. Rev. Med. 2015,50:129-147
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Immune mediated thrombocytopenia
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Pathogenesis of ITP
• Antibody mediated destruction
• T-lymphocyte mediated
• Inadequate production
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What is new
in the treatment of ITP ?
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H. Pylori
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Anti CD20 Antibody
Rituximab
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TPO analogs
•Eltrombopag (Revolade)
•Romiplostim (NPlate)
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Thrombocytopenia with
thrombosis
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Q : One of the following disorders does not cause thrombosis & thrombocytopenia
A. Heparin induced thrombocytopenia
B. Antiphospholipid antibody syndrome
C. Evan’s syndrome
D. Thrombotic thrombocytopenic purpura
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A: One of the following disorders does not cause thrombosis & thrombocytopenia
A. Heparin induced thrombocytopenia
B. Antiphospholipid antibody syndrome
C. Evan’s syndrome
D. Thrombotic thrombocytopenic purpura
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TTP : Pathogenesis
Role of ADAMTS-13
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TTP: Pathogenesis
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Q : One of the following is the best treatment modality for TTP
A. FFP support
B. FFP & platelet support
C. Plasma exchange
D. Rituximab
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A : One of the following is the best treatment modality for TTP
A. FFP support
B. FFP & platelet support
C. Plasma exchange
D. Rituximab
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Plasma exchange for TTP
• It is an emergency
•Plasma exchange & not plasmapheresis
• In emergency : FFP
•Avoid platelet transfusion
•Cryosupernatant
•Follow up with LDH & platelet count
Contreras M et al. Transfusion. 2014;38:796-797
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Investigations
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Investigations
•History
•Examination
•CBC
•Blood film examination
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Q : Give the diagnosis on PS in next slide
A. MAHA
B. Dengue
C. Malaria
D. CMV
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Q : Give the diagnosis on PS in next slide
A. MAHA
B. Dengue
C. Malaria
D. CMV
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A : The film shown to you is diagnostic of
A. MAHA
B. Dengue
C. Malaria
D. CMV
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Blood film examination
•Platelets : Number, size, clumping
•RBC : Schistocytes, spherocytes, parasites
•WBC : Leukocytosis, leukaemia, dysplasia
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Coagulation
•PT, PTT
•Fibrinogen
•D-Dimer
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Blood chemistry
•Haemolysis : Bilirubin, LDH, Haptoglobin
•Hepatic dysfunction : Acute, chronic
•Renal dysfunction : HUS, TTP, DIC, SLE
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USG abdomen for splenic enlargement
and Doppler for portal hypertension
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Bone marrow examination
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Management
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Management - 1
•Treating the cause
•Platelet transfusion
• IVGG, Anti D, steroids
•Antifibrinolytic agents
•NovoSeven
Rintala EOP et al. Crit Care Medicine. 2014;26:965-968
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MCQ : Despite thrombocytopenia, platelet transfusion is most hazardous in
A. TTP & HIT-T
B. ITP & TTP
C. Hypersplenism & DIC
D. HLH & HUS
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MCQ : Despite thrombocytopenia, platelet transfusion is most hazardous in
A. TTP & HIT-T
B. ITP & TTP
C. Hypersplenism & DIC
D. HLH & HUS
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The peril of platelet transfusion
Kruskall MS et al. N Engl J Med. 2013;337:1914-1915
Contraindicated TTP, HIT
Not indicated ITP
Hypersplenism
Indicated Production defects
Others : DIC, dilutional
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Platelet count as the trigger for transfusion
(Clinical judgment is superior to the count)
•Severity
•Associated coagulation defects
•Stability
•Aetiology
Klumpp TR et al. Transfusion. 2014;39:674-681
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