Transcript THROMBOCYTOPENIA - VirtualMedlibrary

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 4F
– 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
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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 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
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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 2ND, 4TH, 6TH, 8TH
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
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EXAMPLES
SCD
HS
THAL
AN APPROACH TO
THROMBOCYTOPENIA CONT’D
• NEOPLASM
• MOA
• BM HYPOFUNCTION LEADS TO COMPENSATORY
EXTRAMEDULLARY HEMATOPOIESIS
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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 - 1ST 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
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VASCULITIS EX. HSP
LEUKEMIA
LYMPHOMA
HUS/TTP
CHILD ABUSE
PATIENT 2
• LABS
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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
• T3/4 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 1GG/IGM/1GA
• DECREASED C3/4
• 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