THROMBOCYTOPENIA PRESENTED BY: BASIL AL-SAIGH, FMR – 1 SUPERVISORS: DR. ESSALAH DR. RUTHNUM DR. DATTA
AGENDA • AN APPROACH TO THROMBOCYTOPENIA (5 STEPS) • 3 CASE REPORTS FROM 4 F – PATIENT 1; C/O DR. ESSALAH – PATIENT 2; C/O DR. RUTHNUM – PATIENT 3; C/O DR. DATTA & DR. ESSALAH
AN APPROACH TO THROMBOCYTOPENIA (5 STEPS)
AN APPROACH TO THROMBOCYTOPENIA • “HOW TO INTERPRET AN ABNORMAL COMPLETE BLOOD COUNT” • MAYO CLINIC PROCEEDINGS JULY 2005; 80(7): 923 -936 • WWW. MAYOCLINICPROCEEDINGS. COM
AN APPROACH TO THROMBOCYTOPENIA CONT’D • KEEP IN MIND THAT USING LOW PLT COUNT TO HELP CLINCH A DX MUST BE IN CONJUNCTION WITH OTHER PEX AND LAB FINDINGS
AN APPROACH TO THROMBOCYTOPENIA CONT’D … • STEP 1
AN APPROACH TO THROMBOCYTOPENIA CONT’D … • R/O SPURIOUS THROMBOCYTOPENIA (SECOND. TO EDTA-INDUCED PLATLET CLUMPING) • SOLUTION : EXAMINE THE PBS (LOOKING FOR PLATLET CLUMPING) OR REPEAT THE CBC WITH SODIUM CITRATE AS AN ANTICOAGULANT
AN APPROACH TO THROMBOCYTOPENIA CONT’D • STEP 2
AN APPROACH TO THROMBOCYTOPENIA CONT’D • R/O HUS/TTP/DIC • REASON : THERE IS AN URGENCY FOR SPECIFIC THERAPY IN THESE DISORDERS
AN APPROACH TO THROMBOCYTOPENIA CONT’D • WHAT TESTS DO WE ORDER FOR DIAGNOSIS OF HUS/TTP?
AN APPROACH TO THROMBOCYTOPENIA CONT’D • CBC & PBS (ANEMIA & SCHISTOCYETES) • SERUM HAPTOGLOBIN (DECREASED) • SERUM LDH (INCREASED) • SERUM CREATININE (INCREASED) • COAGULATION TESTS (EXCLUDE DIC)
CASE 1 C/O DR. ESSALAH
PATIENT 1 • BACKGROUND • PATIENT 1 • 10 Y/O MALE, OTHERWISE HEALTHY • NON-CONTRIBUTING PMHX, PSHX OR FHX AND NKDA
PATIENT 1 • RFC • 09/26/05 - C/O LETHARGY, NON-BLOODY DIARRHEA, LOWER ABD. PAIN, NO APPETITE • 09/28/05 - ABOVE S/S CONT. AND NOW VOMITTING • NAD ON U/S - OPERATD. ON FOR APPEND
PATIENT 1 • RFC CONT’D • POST-OP: ANURIC; CATHETERIZED • 09/29/05 : NON-BLOODY DIARRHEA OF SAME FREQUENCY; VOMITTING; DECREASED APPETITE; STILL ANURIC • 09/30/05 : DR. ESALAH CALLED TO ASSESS FOR ANURIA
PATIENT 1 • QUESTION GIVEN THIS CASE PRESENTATION, WHAT IS YOUR DDX FOR PT. 1?
PATIENT 1 • DDX • PRE-RENAL FAILURE: SEC. TO VOMITTING AND DIARRHEA • RENAL FAILURE • POST-RENAL FAILURE: BILATERAL URETERAL COMPROMISE IN SURGERY
PATIENT 1 • DDX CONT’D • PRE-RENAL FAILURE : PRE-OP VITALS GOOD; PRE-OP IN/OUT GOOD. UNLIKLEY • POST-RENAL FAILURE : OPERATION PERFORMED ON THE RIGHT SIDE OF THE ABDOMOEN SO BILATERAL URETERAL COMPLICATION UNLIKLEY
PATIENT 1 • DDX CONT’D • RENAL FAILURE: THE KIDNEY IS COMPOSED OF 4 COMPARTMENTS: • THE BLOOD VESSELS (CONSIDER HUS) • THE GLOMERULUS (CONSIDER GN) • THE TUBULES (CONSIDER ATN) - MCC • THE INTERSTITIUM (CONSIDER DRUGS/OTHER)
PATIENT 1 • LABS ON ADMISSION • • PLT COUNT : 90 HGB : 140 RET COUNT : 144 LD : 3451 COAG STUDIES : WNL UREA : 27. 5 CREAT : 373
PATIENT 1 • VIRAL STUDIES • VEROTOXIN : + • SHIG/SALM/C. DIFF/ GP. A STREP : -
PATIENT 1 • PATIENT 1 HX RE-VISITED • PRESENTING S/S - MOM NOW STATES THAT PATENT 1 COULD HAVE SOME EPISODES OF BLOODY DIARRHEA • SOCIAL HX – IN GRADE 6 AND DOING V. WELL IN SCHOOL; MOM TEACHING PRE-SCHOOL @ HOME; NO KIDS INFECTIVE; DAD ENGINEER • DIET – BALANCED DIET; EATS BURGERS OCC. @ FRIENDS HOUSE; LAST ATE STEAK/BURGERS FEW DYS BEFORE ADMISSION AND USED MICROWAVE TOO COOK ITIN
PATIENT 1 • WORKING DX OF PATIENT 1: HUS
PATIENT 1 • COMPLICATIONS OF HUS • PHUTS • • PANCREATITIS HEMOLYSIS HEPATIC DYSFUNCTION HEART FAILURE UREMIA (RF) THROMBOCYTOPENIA SEIZURES/NEUROLOGICAL DEFICITS
PATIENT 1 • MANAGEMENT • HUS CAN CAUSE RF • RF CAN CAUSE HYPERKALEMIA, HYPERPHOSPHATEMIA, HYPONATREMIA AND HYPOCALCEMIA : ELECTROLYTE BALANCE AND DIET RESTRICTIONS • RF CAN CAUSE FUID OVERLOAD : FLUID SUPPORT
PATIENT 1 • MANAGEMENT CONT’D • RF CAN CAUSE ANEMIA AND LOW PLT. COUNT: BLOOD AND PLT. TRANSFUSIONS • DIALYSIS INDICATED FOR REFRACTORY HYPERKALEMIA OR IF ABOVE FAILS TO CORRECT ELECTROLYTE IMBALANCES, SEVERE ACIDOSIS OR SEVERE UREMIA
PATIENT 1 • MANAGEMENT CONT’D • SCREEN FOR LIVER, PANCREATIC DYSFUNCTION • MONITOR FOR PLATELET COUNT, RENAL FUNCTION
PATIENT 1 • MGMNT & LABS • DIALYSIS DONE OCTOBER 2 ND, 4 TH, 6 TH, 8 TH FOR SIG. ELEVATED UREA AND CREAT LEVELS • UREA : 42. 9 - 38 - 17. 3 - 25. 2 - 22. 8 - 18. 0 - 12. 2 - 6. 4 • CREAT : 464 - 623 - 715 - 304 - 266 - 552 - 191 - 73 • PLT COUNT : 74 - 26 - 41 - 101 - 146 - 242 - 449 - 281
PATIENT 1 • MGMNT & LABS • HGB : 106 - 82 - 104 - 93 - 107 - 82 - 74 - 76 - 71 • LD : 4098 - 1984 - 1174 • NA AND K : WNL • AMYLASE : 153 - 164 - 113 • LFT : WNL
PATIENT 1 • D/C HOME 10/20/05
AN APPROACH TO THROMBOCYTOPENIA CONT’D • STEP 3
AN APPROACH TO THROMBOCYTOPENIA CONT’D • CONSIDER HYPERSPLENISM • CONSIDER DRUG-INDUCED THROMBOCYTOPENIA
AN APPROACH TO THROMBOCYTOPENIA CONT’D • WHAT PEDIATRIC CONDITIONS CAUSE HYPERSPLENISM?
• BANTI’S
AN APPROACH TO THROMBOCYTOPENIA CONT’D • BLOOD FLOW PROBLEM • MOA • INC. SPLENIC VEIN PRESSURE CAUSING CONGESTION • EXAMPLES • SPLENIC VEIN THROMBOSIS EX. TRAUMA, • PORTAL VEIN THROMOSIS FROM HYPERCOAGULABLE STATE EX. PROTEIN C/S DEFICIENCY, NEPHROTIC ETC. • CIRRHOSIS EX. UNTX INB ERROR OF MET, BILIARY ATRESIA, CONGENITAL HEPATITIS • BUDD-CHIARI SYNDROME • CHF EX. UNCORRECTED VALVULAR DEFECTS, PPHN
AN APPROACH TO THROMBOCYTOPENIA CONT’D • ANEMIA • MOA • RBC ABNORMALITIES & HYPERPLASIA OF THE RE SYSTEM SECOND TO DESTR OF RBC • • EXAMPLES SCD HS THAL
AN APPROACH TO THROMBOCYTOPENIA CONT’D • NEOPLASM • MOA • BM HYPOFUNCTION LEADS TO COMPENSATORY EXTRAMEDULLARY HEMATOPOIESIS • • EXAMPLES APLASTIC ANEMIA MYELOFIBROSIS LEUKEMIAS
CASE 2 C/O DR. RUTHNUM
PATIENT 2 • BACKGROUND • PATIENT 2, 3 Y/O FEMALE • TERMS BABY, BORN TO COCAINE-DEPENDANT MOTHER • OTHERWISE HEALTHY • PRODROMAL TONSILLITIS AND ON AMOX X 7 DAYS ON PRESENTATION
PATIENT 2 • RFC • 10/16/05 - 1 ST NOTED EASY BRUISING FOLLOWING BABY FELL FROM A COUCH • BABY V. IRRITABLE AND HAVING TANTRUMS • MOM DENIES BABY HAS ABD. PAIN • ROS OTHERWISE NON-CONTRIBUTARY
PATIENT 2 • RFC CONT’D • GP REFERRED PATIENT 2 TO THE RGH TO R/O HSP
PATIENT 2 • PEX • GENERALLY PALE • MULTIPLE BRUISES NOTED ON LIPS, BUTTOCKS, ARMS AND LEGS • MULTIPLE PETECHIAE ON CHEST
PATIENT 2 • PEX CONT’D • NOTABLE SPLENOMEGALY 3 -4 CM BELOW COSTAL MARGIN • ENLARGED RIGHT PREAURICULAR AND SUBMAXILLARY LN • REST OF EXAM UNREVIELING
PATIENT 2 • QUESTION • GIVEN THIS PRESENTATION, WHAT SHOULD YOU CONSIDER IN YOUR DDX?
PATIENT 2 • DDX • • • VASCULITIS EX. HSP LEUKEMIA LYMPHOMA HUS/TTP CHILD ABUSE
PATIENT 2 • LABS • • • PLT 17 WBC 75. 3 RBC 2. 09 HGB 65 MCV 87. 5 LD 1355 UREA 330 PT 14. 6 MONO TEST -VE BLASTS NOTED
PATIENT 2 • WORKING DX OF PATIENT 2 : ALL
PATIENT 2 • MANAGEMENT • IN ANTICIPATION FOR CHEMO, BABY RECEIVED AN ECHO FOR BASELINE HEART FUNCTION AND URIC ACID LEVELS WERE NOTED TO BE WNL • TRANSFERRED CARE TO PASQUA TO SEE ONCOLOGIST
AN APPROACH TO THROMBOCYTOPENIA CONT’D • THYROTOXICOSIS • MOA • T 3/4 INDUCED LYMPHOID HYPERPLASIA • EXAMPLES • GRAVES DISEASE
AN APPROACH TO THROMBOCYTOPENIA CONT’D • INFECTION • • EXAMPLES MALARIA MONO HIV • SARCOID/SLE/SYSTEMIC DZ
AN APPROACH TO THROMBOCYTOPENIA CONT’D • WHAT DRUGS ARE IMPLICATED IN THROMBOCYTOPENIA?
AN APPROACH TO THROMBOCYTOPENIA CONT’D • ABX EX. TMP-SMX : EX. UTI • CARDIAC MEDS EX. QUINIDINE, PROCAINAMIDE • DIURETIC MEDS (THIAZIDES) : EX. MCD • ANTI-RHEUMATICS : EX. RF
AN APPROACH TO THROMBOCYTOPENIA CONT’D • DO NOT MISS HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) • CAN CONFIRM WITH IN VITRO TESTING OF HEPARIN DEPENDANT PLATELET ANTIBODIES • REQUIRES IMMEDIATE CESSATION OF DRUG USE
AN APPROACH TO THROMBOCYTOPENIA CONT’D • STEP 4
AN APPROACH TO THROMBOCYTOPENIA CONT’D • RULE OUT ISOLATED THROMBOCYTOPENIA • USUALLY THESE ARE INHERITED • WILL SEE GIANT PLATELETS ON PBS
AN APPROACH TO THROMBOCYTOPENIA CONT’D • MAY-HEGGLIN ANOMALY : AD BLOOD D/O; SEE DOHLE BODIES IN LEKOCYTES • BERNARD-SOULIER SYNDROME : AR BLOOD D/O; DEFICIENCY OF PLATLET GLYCOPROTEIN • WISKOTT-ALDRICK SYNDROME : XR D/O WITH ECZEMA, LOW LATLETS AND INCREASED INFECTIONS
AN APPROACH TO THROMBOCYTOPENIA CONT’D • STEP 5
AN APPROACH TO THROMBOCYTOPENIA CONT’D • CONSIDER THE DIAGNOSIS OF ITP DIAGNOSIS OF EXCLUSION !!!
FINAL CASE - CASE 3 C/O DR. DATTA & DR. ESSALAH
PATIENT 3 • BACKGROUND • 3 Y/O FEMALE • EAR INFECTION 1/12 AGO • NO RASHES, NO ABD. PAIN, NO N/V/D/C • REST OF HX NON-CONT.
PATIENT 3 • RFC • 10/24/05 - PERIORBITAL EDEMA, MOST NOTABLE IN AM; DECREASED U/O SINCE 10/19/05 • DENIES SORE THROAT OR RECENT HX OF URTI
PATIENT 3 • PEX • NAD • AFEBRILE, 130/100 • FACIAL SWELLING
PATIENT 3 • PEX CONT’D • ABDOMINAL DISTENTION • NO RASHES • REST OF EXAM UNREVIELING
PATIENT 3 • DDX • GN, LIKLEY POST-STREPTOCOCCAL • NEPHROTIC SYNDROME • NEPHRITIC SYNDROME
PATIENT 3 • LABS • DECREASED PLT COUNT, HEMATURIA • HYPERKALEMIA, HYPERPHOSPHATEMIA • HYPOCALCEMIA • INCREASED UREA, SLIGHT INC. IN CREAT • DECREASED ALBUMIN • INCREASED ESR, INCREASED CRP • NORMOCHROMIC ANEMIA, NORMAL FE STUDIES
PATIENT 3 • LABS • GRP A STREP –VE, AGBM –VE • ANA –VE, ASO –VE • INCREASED 1 GG/IGM/1 GA • DECREASED C 3/4 • MICROALBUMIN/CREAT RATIO 820 • URINALYSIS: RBC CASTS • U/S: NO HYDRONEPHROSIS
PATIENT 3 • WORKING DX FOR PATIENT 3 WAS GN, ETIOLOGY NYD
PATIENT 3 • MANAGEMENT • AS WITH PATIENT 1, WHO DEVELOPED RF SECONDARY TO HUS, YOU TX THE ELECTROLYTE ABNORMALITIES, MANAGE THE FLUID STATUS AND MONITOR THE BP AND URINE INS/OUTS
PATIENT 3 • MANAGEMENT CONT’D • TX OF HYPERKALEMIA WITH KAYEXLATE • LASIX FOR EDEMA • STARTED ON CCB FOR HTN
PATIENT 3 • MANAGEMENT CONT’D • DAILY U/O, WT AND BP • WILL R/A TODAY FOR RENAL BX
PATIENT 3 • IN KEEPING WITH TODAY’S TOPIC, WHAT CAUSED THE THROMBOCYTOPENIA IN THIS PATIENT? • WHAT IS THE MOST LIKLEY ETIOLOGY OF PATIENT 3’S PRESENTING COMPLAINTS?
THROMBOCYTOPENIA PRESENTED BY: BASIL AL-SAIGH, FMR – 1 SUPERVISORS: DR. ESSALAH DR. RUTHNUM DR. DATTA
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