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ThrombocytopeniaThrombocytopenia

Selim Krim, MDSelim Krim, MD

Assistant ProfessorAssistant Professor

TTUHSCTTUHSC

Case 1Case 1

• A 35-year-old woman is hospitalized for A 35-year-old woman is hospitalized for recurrent thrombophlebitis and a recurrent thrombophlebitis and a pulmonary embolus and is started on pulmonary embolus and is started on heparin. heparin.

• Two weeks earlier, she had completed a 6-Two weeks earlier, she had completed a 6-month anticoagulation therapeutic month anticoagulation therapeutic regimen. A CBC on day 5 of her regimen. A CBC on day 5 of her hospitalization shows a platelet count of hospitalization shows a platelet count of 70,000/mm3. 70,000/mm3.

MCQ 1MCQ 1• Which of the following is NOT Which of the following is NOT

associated with thrombocytopenia?associated with thrombocytopenia?

• Thrombotic thrombocytopenia purpuraThrombotic thrombocytopenia purpura• Immune thrombocytopenic purpuraImmune thrombocytopenic purpura• Heparin induced thrombocytopenia Heparin induced thrombocytopenia • CirrhosisCirrhosis• Polycythemia veraPolycythemia vera

MCQ 2MCQ 2

• Which is NOT associated with TTP?Which is NOT associated with TTP?

• Megaloblastic anemiaMegaloblastic anemia• FeverFever• Central nervous system signsCentral nervous system signs• ThrombocytopeniaThrombocytopenia• Renal dysfunctionRenal dysfunction

MCQ 3MCQ 3

• Which drug has NOT been implicated Which drug has NOT been implicated as a possible cause of TTP?as a possible cause of TTP?

• TiclopidineTiclopidine• CyclosporineCyclosporine• TacrolimusTacrolimus• QuinineQuinine• FluorouracilFluorouracil

MCQ 4MCQ 4

• Which is INCORRECT about ITP?Which is INCORRECT about ITP?

• It is as common in children as it is in adultsIt is as common in children as it is in adults• It occurs more in adults men than in adult It occurs more in adults men than in adult

womenwomen• It can be secondary to other diseasesIt can be secondary to other diseases• A bone marrow is not required for all patientsA bone marrow is not required for all patients• Evans syndrome describes a combination of Evans syndrome describes a combination of

hemolytic anemia with ITPhemolytic anemia with ITP

MCQ 5MCQ 5

• Which treatment is NOT indicated for Which treatment is NOT indicated for ITP? ITP?

• CorticosteroidsCorticosteroids• Intravenous immunoglobulinIntravenous immunoglobulin• PlasmapheresisPlasmapheresis• Anti-D immune globulinAnti-D immune globulin• SplenectomySplenectomy

MCQ 6MCQ 6

• Which of the following patient Which of the following patient populations has the highest risk of populations has the highest risk of HIT (assume all are receiving the HIT (assume all are receiving the same dose of heparin)?same dose of heparin)?

• After general surgeryAfter general surgery• Hospitalized pediatric patientsHospitalized pediatric patients• After orthopedic surgery After orthopedic surgery • Hospitalized general internal medicine Hospitalized general internal medicine

patientspatients• Hospitalized obstetric patientsHospitalized obstetric patients

MCQ 7MCQ 7

• Which is least suggestive of HIT?Which is least suggestive of HIT?

• Platelet count<20,000/ mm3Platelet count<20,000/ mm3• Venous thrombosisVenous thrombosis• Arterial thrombosisArterial thrombosis• Low molecular-weight heparin use Low molecular-weight heparin use

within the previous weekwithin the previous week• Abnormal serotonin release assayAbnormal serotonin release assay

MCQ 8MCQ 8

• How should one monitor for HIT in patients How should one monitor for HIT in patients receiving heparin after undergoing receiving heparin after undergoing orthopedic surgery?orthopedic surgery?

• Daily platelet countsDaily platelet counts• Platelet counts every other day from day 4 to 14 Platelet counts every other day from day 4 to 14

of heparin treatmentof heparin treatment• Platelet counts at days 7 and 14 of heparin Platelet counts at days 7 and 14 of heparin

treatmenttreatment• Antibody levels for all patients at day 14 of Antibody levels for all patients at day 14 of

therapytherapy• Never unless thrombosis is suspectedNever unless thrombosis is suspected

MCQ 9MCQ 9

• Which is NOT considered important Which is NOT considered important in the initial treatment of HIT type in the initial treatment of HIT type II?II?

• Discontinuation of all heparinDiscontinuation of all heparin• Avoidance of warfarinAvoidance of warfarin• Initiation of Argatroban Initiation of Argatroban • Initiate aspirin therapyInitiate aspirin therapy

Key PointsKey Points

• Consider TTP if the following pentad is Consider TTP if the following pentad is met: fever, renal failure, met: fever, renal failure, thrombocytopenia, CNS involvement, thrombocytopenia, CNS involvement, and microangiopathic hemolytic and microangiopathic hemolytic anemia. anemia.

• ITP is more common in females and ITP is more common in females and equally affects children and adults.equally affects children and adults.

• HIT is most often encountered in HIT is most often encountered in

orthopedic patients taking heparin. orthopedic patients taking heparin.

Key PointsKey Points

• HIT can cause a coagulopathy with HIT can cause a coagulopathy with venous or arterial thrombi. venous or arterial thrombi.

• If HIT occurs, all heparin products If HIT occurs, all heparin products should be discontinued and a non-should be discontinued and a non-heparin, non-warfarin anticoagulant heparin, non-warfarin anticoagulant should be initiated. should be initiated.

• In HIT alternative anticoagulation should In HIT alternative anticoagulation should continue for at least 2 weeks after continue for at least 2 weeks after heparin has been discontinued. heparin has been discontinued.

Thank YouThank You