Issues in the Diagnosis Issues in the Diagnosis and Management of and Management of Thombocytopenic Thombocytopenic

DisordersDisorders

Alice Ma, M.D.Alice Ma, M.D.HematologyHematology

UNC-CHUNC-CHAugust 10, 2009August 10, 2009

OverviewOverview

• Normal PhysiologyNormal Physiology• Categories of Categories of

ThrombocytopeniasThrombocytopenias• ITPITP• TTPTTP• HITHIT

Normal Physiology-Normal Physiology-Production and NumberProduction and Number

• Platelets are normally made Platelets are normally made in the bone marrow from in the bone marrow from progenitor cells known as progenitor cells known as megakaryocytesmegakaryocytes..

• Normal platelet lifespan is Normal platelet lifespan is 10d. Every day, 1/10 of 10d. Every day, 1/10 of platelet pool is replenished.platelet pool is replenished.

• Normal platelet count is Normal platelet count is between 150,000 and between 150,000 and 450,000/mm450,000/mm33

Platelet Platelet ResponseResponse

•Platelets provide phospholipid Platelets provide phospholipid

scaffold for thrombin scaffold for thrombin

generation.generation.

•Platelets Platelets

adhere to adhere to

vessel wall, vessel wall,

then then

aggregate, aggregate,

leading to leading to

formation of a formation of a

platelet plugplatelet plug

Thrombocytopenia-Thrombocytopenia-How low is too low?How low is too low?

• 150,000 - 50,000: no symptoms150,000 - 50,000: no symptoms– No treatment generally required.No treatment generally required.

• 50,000 - 20,000: first symptoms50,000 - 20,000: first symptoms– Generally need to begin therapyGenerally need to begin therapy

• 20,000-10,000: life-threatening20,000-10,000: life-threatening– Generally requires hospitalizationGenerally requires hospitalization

• <<10,00010,000: risk for spontaneous : risk for spontaneous intracranial hemorrhageintracranial hemorrhage

ThrombocytopeniaThrombocytopenia3 broad categories of 3 broad categories of

causescauses

•PseudothrombocytopeniaPseudothrombocytopenia

•UnderproductionUnderproduction•Splenic sequestrationSplenic sequestration•Peripheral DestructionPeripheral Destruction

PseudothrombocytopeniaPseudothrombocytopenia

• Platelet clumping is of no clinical Platelet clumping is of no clinical significancesignificance• No increased risk of bleeding or clottingNo increased risk of bleeding or clotting

Thrombocytopenia - Thrombocytopenia - Peripheral Destruction Peripheral Destruction

• Non-immune mechanisms: Non-immune mechanisms: – Platelet activation and Platelet activation and

consumptionconsumption– e.g. TTP and DICe.g. TTP and DIC

• Immune Mechanisms: Immune Mechanisms: – antibody-mediated platelet antibody-mediated platelet

destructiondestruction– may be primary, secondary, or may be primary, secondary, or

drug-induceddrug-induced..

ITP - Immune/Idiopathic ITP - Immune/Idiopathic Thrombocytopenic PurpuraThrombocytopenic Purpura

• DefinitionDefinition: isolated thrombocytopenia : isolated thrombocytopenia with no clinically apparent associated with no clinically apparent associated conditions or other causes of conditions or other causes of thrombocytopenia.thrombocytopenia.

• EtiologyEtiology: autoantibodies directed : autoantibodies directed against platelets coat platelet surface. against platelets coat platelet surface. IgG-coated platelets are taken up by RE IgG-coated platelets are taken up by RE system.system.

• IncidenceIncidence: approximately 100 per : approximately 100 per million; half of these are children. In million; half of these are children. In adults, two peaks:adults, two peaks:– one are young (<40) with female one are young (<40) with female

predominance, predominance, – one are older (>60), no gender predominance.one are older (>60), no gender predominance.

ITP - DiagnosisITP - Diagnosis

• ITP is a Diagnosis of ITP is a Diagnosis of ExclusionExclusion

• No laboratory test can No laboratory test can diagnose ITPdiagnose ITP

• Need to exclude other Need to exclude other causes of causes of thrombocytopeniathrombocytopenia

Evaluation of Patient with Low Evaluation of Patient with Low PlateletsPlatelets

• History History – Has the patient ever had a normal platelet Has the patient ever had a normal platelet

count?count?– Carefully review medications, including OTC Carefully review medications, including OTC

meds.meds.• Antibiotics, quinine, anti-seizure Antibiotics, quinine, anti-seizure

medicationsmedications– Ask about other conditions which may be Ask about other conditions which may be

associated with low plateletsassociated with low platelets• Liver Disease/hepatitisLiver Disease/hepatitis• Thyroid Disease - both hypo- and hyper-Thyroid Disease - both hypo- and hyper-• Infections: viral, rickettsialInfections: viral, rickettsial• PregnancyPregnancy

– Ask about other conditions which may be Ask about other conditions which may be associated with ITPassociated with ITP• Lupus, CLL, lymphomaLupus, CLL, lymphoma

Evaluation of Patient with Low Evaluation of Patient with Low PlateletsPlatelets

• PhysicalPhysical– Evaluate for lymphadenopathy and Evaluate for lymphadenopathy and

splenomegalysplenomegaly– Look for stigmata of bleedingLook for stigmata of bleeding– Blood blisters and oral petechiae, ie “Wet Blood blisters and oral petechiae, ie “Wet

Purpura” Purpura” • best harbinger of intracranial hemorrhagebest harbinger of intracranial hemorrhage

• Laboratory DataLaboratory Data– Other blood counts should be normal.Other blood counts should be normal.– Check B12 and folate levels. Check B12 and folate levels. – Look at peripheral smear to exclude Look at peripheral smear to exclude

pseudothrombocytopenia, also exclude TTP pseudothrombocytopenia, also exclude TTP (especially if anemia also present.)(especially if anemia also present.)

– Send coagulation screens (PT/PTT) to exclude Send coagulation screens (PT/PTT) to exclude DICDIC

– Send HIV, hepatitis serologies and TSHSend HIV, hepatitis serologies and TSH• Consider doing a bone marrow biopsyConsider doing a bone marrow biopsy

– Megakaryocytes should be present.Megakaryocytes should be present.

Management of ITPManagement of ITPAsymptomatic AdultAsymptomatic Adult

• If platelet count is >40-50 K, If platelet count is >40-50 K, no therapy is required. Check no therapy is required. Check platelet counts at designated platelet counts at designated intervals.intervals.

• If platelet count is < 20-30 K, If platelet count is < 20-30 K, begin therapy with begin therapy with corticosteroidscorticosteroids. .

• Stop all NSAIDS and ASA to Stop all NSAIDS and ASA to improve platelet function.improve platelet function.

Initial Management of ITPInitial Management of ITPAdult with Symptomatic Adult with Symptomatic

PurpuraPurpura• If platelet count is >10, treat with If platelet count is >10, treat with

prednisoneprednisone alone - use 1 mg/kg. alone - use 1 mg/kg.• If platelet count <10, treat with If platelet count <10, treat with

prednisone, but also add prednisone, but also add IVIgIVIg 1g/kg/d x 2d. - may require 1g/kg/d x 2d. - may require admissionadmission

• Along with prednisone, add Along with prednisone, add Calcium and Vitamin D to prevent Calcium and Vitamin D to prevent bone loss.bone loss.

• If patient has severe bleeding, If patient has severe bleeding, may need may need platelet transfusionsplatelet transfusions..

Subsequent Management of Subsequent Management of ITPITP

Adult with Symptomatic Adult with Symptomatic PurpuraPurpura• Follow platelet counts daily until Follow platelet counts daily until

>20, then can d/c patient with >20, then can d/c patient with close follow-upclose follow-up

• Once platelet count normalizes, Once platelet count normalizes, commence a commence a slow steroid taperslow steroid taper over 6-8 weeks.over 6-8 weeks.

• 1/3 of adults will have gone into 1/3 of adults will have gone into remission.remission.

• 2/3 of patients will relapse during 2/3 of patients will relapse during or after steroid taper. or after steroid taper.

Management of Relapsed ITPManagement of Relapsed ITP

• Once the patient relapses, may Once the patient relapses, may need to use steroids to increase need to use steroids to increase the platelet count out of the the platelet count out of the danger range, but danger range, but THIS CANNOT THIS CANNOT SUBSTITUTE FOR DEFINITIVE SUBSTITUTE FOR DEFINITIVE THERAPYTHERAPY..

• Prednisone is now a crutch to Prednisone is now a crutch to support a dangerously low support a dangerously low platelet count.platelet count.

• Options now include Options now include splenectomysplenectomy (standard of care) or intermittent (standard of care) or intermittent treatment with treatment with anti-D immune anti-D immune globulinglobulin (WinRho®). (WinRho®).

Management of Relapsed ITPManagement of Relapsed ITPSplenectomySplenectomy

• Splenectomy is effective in 2/3 of Splenectomy is effective in 2/3 of patients, leading to normal patients, leading to normal platelet counts.platelet counts.

• Can be performed via open Can be performed via open method or laparoscopically.method or laparoscopically.

• Need to vaccinate against Need to vaccinate against encapsulated bacteria 2 weeks encapsulated bacteria 2 weeks before procedure. before procedure.

• May need steroids and/or IVIg May need steroids and/or IVIg before procedure to boost platelet before procedure to boost platelet counts preoperatively.counts preoperatively.

Management of Relapsed Management of Relapsed ITPITP

Anti-D Immune GlobulinAnti-D Immune Globulin• Can be used as a substitute for IVIg for Can be used as a substitute for IVIg for

maintenance therapymaintenance therapy• Especially useful in patients with Especially useful in patients with

contraindications to splenectomy.contraindications to splenectomy.• Coats red cells with IgG and allows red Coats red cells with IgG and allows red

cells to serve as decoy for splenic cells to serve as decoy for splenic macrophages.macrophages.

• Patient must be Rh positive. Patient must be Rh positive. • Not effective after splenectomy.Not effective after splenectomy.• Designed to cause hemolytic anemia--Designed to cause hemolytic anemia--

Hgb may drop as much as 3g/dl.Hgb may drop as much as 3g/dl.• Intermittent dosing may allow patients Intermittent dosing may allow patients

to avoid splenectomy.to avoid splenectomy.

Case 1Case 1• A 19 y.o. female college A 19 y.o. female college

student presents with a rash student presents with a rash over her lower extremities. over her lower extremities. She had a viral illness 2 She had a viral illness 2 weeks ago. She has no other weeks ago. She has no other medical problems, and she medical problems, and she takes no medications.takes no medications.

• Physical examination reveals Physical examination reveals petechiae over the shins.petechiae over the shins.

• Platelet count is 20K.Platelet count is 20K.

Case 1Case 1

• The patient is begun on The patient is begun on prednisone at 1 mg/kg. prednisone at 1 mg/kg.

• Seven days later, the patient Seven days later, the patient returns, complaining of acne, returns, complaining of acne, insomnia, severe indigestion, insomnia, severe indigestion, and visual hallucinations. and visual hallucinations. The platelet count is 250K. The platelet count is 250K. Prednisone dose is tapered Prednisone dose is tapered over 8 weeks, and the patient over 8 weeks, and the patient remains asymptomatic with remains asymptomatic with normal platelet counts.normal platelet counts.

Case 2Case 2• A 39 y.o. man presents with A 39 y.o. man presents with

epistaxis to the ER. He has no epistaxis to the ER. He has no medical problems, and he medical problems, and he takes no medications. He takes no medications. He works as a taxi driver and has works as a taxi driver and has no occupational exposures. no occupational exposures. He is married and has 3 He is married and has 3 children. children.

• Physical examination is Physical examination is remarkable only for epistaxis remarkable only for epistaxis and scattered petechiae.and scattered petechiae.

• The platelet count is 35KThe platelet count is 35K

Case 2Case 2

• HIV testing is positive, and HIV testing is positive, and the patient admits to having the patient admits to having numerous unprotected numerous unprotected homosexual encounters. The homosexual encounters. The CD4 count is 140, and the CD4 count is 140, and the patient is started on patient is started on antiretrovirals. The platelet antiretrovirals. The platelet count slowly rises to normal.count slowly rises to normal.

Case 3Case 3

• A 46 y.o. woman is found to A 46 y.o. woman is found to have a platelet count of 20 on have a platelet count of 20 on routine laboratory testing. routine laboratory testing. She has some easy bruising She has some easy bruising and gum bleeding, but admits and gum bleeding, but admits to not flossing. to not flossing.

• She has no PMHx, and is on She has no PMHx, and is on no medications. She works as no medications. She works as a school principal.a school principal.

• She is started on 1 mg/kg of She is started on 1 mg/kg of prednisone. prednisone.

Case 3Case 3• After 1 week, the platelet count After 1 week, the platelet count

is 180, and the prednisone dose is 180, and the prednisone dose is tapered by 10 mg per week. is tapered by 10 mg per week. When she reaches a dose of 10 When she reaches a dose of 10 mg qd, the patient develops mg qd, the patient develops severe menstrual bleeding and severe menstrual bleeding and is noted to have a platelet count is noted to have a platelet count of 8k.of 8k.

• She is admitted to the hospital, She is admitted to the hospital, and is begun on IVIg at 1g/kg IV and is begun on IVIg at 1g/kg IV qd x 2d. The prednisone dose is qd x 2d. The prednisone dose is increased to 60 mg daily. By increased to 60 mg daily. By the third day, the platelet count the third day, the platelet count is 60K.is 60K.

Case 3Case 3

• The patient is vaccinated The patient is vaccinated against pneumococcus, against pneumococcus, meningococccus, and meningococccus, and Hemophilus influenzae. Hemophilus influenzae.

• She undergoes laparascopic She undergoes laparascopic splenectomy, which is splenectomy, which is uneventful. The platelet uneventful. The platelet count rises to 600K. She is count rises to 600K. She is successfully weaned off successfully weaned off steroids. steroids.

Management of Refractory Management of Refractory ITPITP

• One third of patients will have an One third of patients will have an inadequate response to inadequate response to splenectomy.splenectomy.

• Management of these patients Management of these patients involves accepting that they have involves accepting that they have a chronic, incurable condition.a chronic, incurable condition.

• Target platelet counts should be Target platelet counts should be lower--aim for about 30K or lower--aim for about 30K or absence of bleeding.absence of bleeding.

Treatment of Refractory ITPTreatment of Refractory ITP• Immunosuppressive agentsImmunosuppressive agents

– Rituximab (anti-CD20)Rituximab (anti-CD20)• No RTCs vs splenectomyNo RTCs vs splenectomy• 40% effective40% effective• May be used before splenectomy May be used before splenectomy

– Mycophenolate mofetilMycophenolate mofetil– CyclophosphamideCyclophosphamide

• Adjunct agentsAdjunct agents– Thrombopoietin Receptor AgonistsThrombopoietin Receptor Agonists

• RomiplostimRomiplostim• EltrombopagEltrombopag

Drugs Commonly Drugs Commonly Implicated in Implicated in

ThrombocytopeniaThrombocytopenia• Beta-lactam antibiotics.Beta-lactam antibiotics.• Trimethoprim-sulfamethoxazole Trimethoprim-sulfamethoxazole

and other sulfa drugs.and other sulfa drugs.• Vancomycin.Vancomycin.• Quinine/quinidine.Quinine/quinidine.• Heparin.Heparin.• Abciximab (ReoPro®).Abciximab (ReoPro®).• HH22 blockers blockers• If a patient’s platelets fall, ALL If a patient’s platelets fall, ALL

unnecessary drugs need to be unnecessary drugs need to be stoppedstopped..

Case 4Case 4• A 55 y.o. woman presented with A 55 y.o. woman presented with

bleeding from her nose and mouth bleeding from her nose and mouth and gums. and gums.

• PMHx - HTN, DM, DJDPMHx - HTN, DM, DJD• Medications - glucotrol, Medications - glucotrol,

glucophage, HCTZ, quinine for leg glucophage, HCTZ, quinine for leg crampscramps

• PEx - petechiae over limbs and PEx - petechiae over limbs and torso, blood blisters in mouth, torso, blood blisters in mouth, epistaxis.epistaxis.

• Platelet count 2KPlatelet count 2K

Case 4Case 4

• Pt admitted to hospital, Pt admitted to hospital, quinine stopped, patient quinine stopped, patient treated with platelet treated with platelet transfusions and IVIg.transfusions and IVIg.

• Platelet count rose to normal Platelet count rose to normal over the next 5-6 days.over the next 5-6 days.

• Eight months later, Eight months later, thrombocytopenia recurred, thrombocytopenia recurred, and patient admitted to and patient admitted to taking quinine again for taking quinine again for recurrent leg cramps.recurrent leg cramps.

Drug Induced ITPDrug Induced ITP

• Usually, removing the Usually, removing the offending agent is enough to offending agent is enough to allow the platelets to rise on allow the platelets to rise on their own.their own.

• If platelets are severely low, If platelets are severely low, platelet transfusions may be platelet transfusions may be required.required.

• IVIg is particularly helpful in IVIg is particularly helpful in quinine-induced ITP.quinine-induced ITP.

Case 5Case 5• A 65 y.o. male smoker with a A 65 y.o. male smoker with a

h/o peripheral vascular disease h/o peripheral vascular disease presented to the ER with presented to the ER with unstable angina. He was unstable angina. He was admitted to the hospital and admitted to the hospital and placed on heparin. Platelet placed on heparin. Platelet count on admission was 450. count on admission was 450. Cardiac catheterization Cardiac catheterization showed severe 3-vessel showed severe 3-vessel coronary disease, and the coronary disease, and the patient was scheduled for patient was scheduled for CABG which occurred on CABG which occurred on hospital day #7. Pre-op hospital day #7. Pre-op platelet count was 200. Post-platelet count was 200. Post-op platelet count was 90.op platelet count was 90.

Case 5Case 5• On hospital day #12, the On hospital day #12, the

patient developed acute left leg patient developed acute left leg swelling and a DVT was swelling and a DVT was diagnosed by ultrasound. diagnosed by ultrasound. Platelet count was 150. The Platelet count was 150. The patient was started on IV patient was started on IV heparin. The next day, he heparin. The next day, he developed a pulseless left leg developed a pulseless left leg and had a platelet count of 30. and had a platelet count of 30. While in vascular radiology, he While in vascular radiology, he developed acute chest pain and developed acute chest pain and suffered a cardiac arrest and suffered a cardiac arrest and subsequently died. Autopsy subsequently died. Autopsy showed occlusion of all of his showed occlusion of all of his bypass grafts.bypass grafts.

Heparin-Induced Heparin-Induced ThrombocytopeniaThrombocytopenia

• Seen in 1-3% of patients treated with Seen in 1-3% of patients treated with heparinheparin

• Usually, 7-10 d after heparin started, Usually, 7-10 d after heparin started, platelets fall by at least 1/3 to 1/2. platelets fall by at least 1/3 to 1/2. – Patients Patients do not have to be do not have to be

thrombocytopenicthrombocytopenic. . – Can occur earlier in patients who have been Can occur earlier in patients who have been

previously exposed to heparin, even as SQ previously exposed to heparin, even as SQ injections.injections.

• Caused by antibodies against the Caused by antibodies against the complex of heparin and PF4. These complex of heparin and PF4. These antibodies activate platelets.antibodies activate platelets.

• Can lead, paradoxically, to Can lead, paradoxically, to THROMBOSISTHROMBOSIS, in up to half of patients., in up to half of patients.

• More common in patients with vascular More common in patients with vascular diseasedisease

Alternate Presentations of HIT/TAlternate Presentations of HIT/T

• Small drop in platelet count Small drop in platelet count

(especially with skin necrosis)(especially with skin necrosis)

• Earlier onset thrombocytopenia Earlier onset thrombocytopenia

with heparin re-exposurewith heparin re-exposure

• Delayed-onset Delayed-onset

thrombocytopenia/ thrombosis thrombocytopenia/ thrombosis

after stopping heparinafter stopping heparin

• Thrombosis after heparin Thrombosis after heparin

exposureexposure

HIT/T treatmentHIT/T treatment

1.1. IF PLATELETS FALL ON IF PLATELETS FALL ON HEPARIN, STOP HEPARIN HEPARIN, STOP HEPARIN IMMEDIATELY.IMMEDIATELY.

2.2. Stop heparinStop heparin3.3. Stop heparinStop heparin4.4. Use a different Use a different

anticoagulantanticoagulant1.1. LepirudinLepirudin2.2. ArgatrobanArgatroban

Case 6Case 6

• A 75 y.o.man presented with A 75 y.o.man presented with fever, nausea, vomiting, fever, nausea, vomiting, epigastric pain with radiation epigastric pain with radiation to his back. Amylase 12,000, to his back. Amylase 12,000, Lipase 3000. Patient treated Lipase 3000. Patient treated for pancreatitis. On Hospital for pancreatitis. On Hospital day 2, hemoglobin and day 2, hemoglobin and platelet count both noted to platelet count both noted to drop. By hospital day 4, Hgb drop. By hospital day 4, Hgb 7, Plts 12. PT/PTT normal. 7, Plts 12. PT/PTT normal. Amylase and lipase nl, LDH Amylase and lipase nl, LDH 5000, Cre 2.8.5000, Cre 2.8.

TTP - Diagnostic Features TTP - Diagnostic Features (aka “the Pentad”)(aka “the Pentad”)

• Microangiopathic Hemolytic Anemia Microangiopathic Hemolytic Anemia (MAHA)(MAHA)– Elevated LDH, elevated bilirubinElevated LDH, elevated bilirubin– SchistocytesSchistocytes on the peripheral smear on the peripheral smear– MUST BE PRESENTMUST BE PRESENT

• Low plateletsLow platelets - MUST BE PRESENT - MUST BE PRESENT

• FeverFever• Neurologic ManifestationsNeurologic Manifestations - headache, - headache,

sleepiness, confusion, stupor, stroke, coma, sleepiness, confusion, stupor, stroke, coma, seizuresseizures

• Renal ManifestationsRenal Manifestations - hematuria, - hematuria, proteinuria, elevated BUN/Creatinineproteinuria, elevated BUN/Creatinine

• Abdominal PainAbdominal Pain - can see elevated - can see elevated lipase/amylaselipase/amylase

TTP - etiologyTTP - etiology

• May be associated with an May be associated with an antibody against or a deficiency of antibody against or a deficiency of the protease which cleaves the the protease which cleaves the ultra-high molecular weight ultra-high molecular weight multimers of von Willebrand’s multimers of von Willebrand’s factor. These very high molecular factor. These very high molecular weight vWF multimers cause weight vWF multimers cause abnormal platelet activation. abnormal platelet activation.

• Can be induced byCan be induced by drugsdrugs, , including ticlopidine, quinine, including ticlopidine, quinine, cyclosporine, tacrolimus, cyclosporine, tacrolimus, mitomycin C.mitomycin C.

• Increased incidence with Increased incidence with pregnancypregnancy or or HIVHIV

TTP - Course and TTP - Course and PrognosisPrognosis

• 95% fatal prior to therapy, now 5% fatal.95% fatal prior to therapy, now 5% fatal.• Treatment relies on Treatment relies on PLASMA EXCHANGE.PLASMA EXCHANGE.

– Plasma exchange is superior to plasma Plasma exchange is superior to plasma infusion, but if PLEX is delayed, give FFP.infusion, but if PLEX is delayed, give FFP.

• Remove all inciting agents.Remove all inciting agents.

• Platelet transfusions contra-Platelet transfusions contra-indicated.indicated. – Multiple case reports of stroke and/or death Multiple case reports of stroke and/or death

during or immediately after platelet during or immediately after platelet transfusion.transfusion.

– Can consider giving if life-threatening Can consider giving if life-threatening hemorrhage is present, but avoid routine hemorrhage is present, but avoid routine platelet transfusions.platelet transfusions.

• Secondary measures if no response to Secondary measures if no response to plasma exchange include plasma exchange include splenectomysplenectomy, , vincristinevincristine

HUS - Hemolytic Uremic HUS - Hemolytic Uremic SyndromeSyndrome

• Usually classified along with TTP Usually classified along with TTP as “TTP/HUS”as “TTP/HUS”

• Has fewer neurologic sequelae, Has fewer neurologic sequelae, more renal manifestations.more renal manifestations.

• Usually precipitated by diarrheal Usually precipitated by diarrheal illness, especially illness, especially E. coli O157:H7E. coli O157:H7 or Shigellaor Shigella

• Seen more in pediatric patients, Seen more in pediatric patients, usually has better prognosis. May usually has better prognosis. May respond less well to plasma respond less well to plasma exchange.exchange.

WrapupWrapup

• Platelet count <20Platelet count <20– Usually requires admissionUsually requires admission– R/O TTPR/O TTP– Stop all meds, if possibleStop all meds, if possible– Probably ITPProbably ITP– Send HIVSend HIV

WrapupWrapup

• Platelet count b/w 20-50Platelet count b/w 20-50– R/O TTPR/O TTP– Probably requires treatmentProbably requires treatment– Stop all medsStop all meds– Send HIVSend HIV

WrapupWrapup

• Platelet count b/w 50-100Platelet count b/w 50-100– Probably does not require Probably does not require

treatmenttreatment– Find old CBCs to see if new or Find old CBCs to see if new or

oldold– Stop all meds, if possibleStop all meds, if possible– Careful follow-up to see if Careful follow-up to see if

platelet count remains stableplatelet count remains stable– If pt is elderly, may be MDS, o/w If pt is elderly, may be MDS, o/w

probably chronic ITPprobably chronic ITP