Department of Hematology
Ren Ji Hospital
26 year-old, female patient
persistent nasal bleeding for one day, have an upper respiratory infection 2 weeks previously. No fever, chills, nausea,
vomiting, abdominal pain, or joint pain.
PE: multiple l-mm reddish spots on her lower extremities.
No lymphadenopathy or hepatosplenomegaly.
epistaxis, easy bruisability, or bleeding into her joints.
No family history of abnormal bleeding.
Not take any medication.
Objects of Analysis
Learn the clinical approach to bleeding disorders, specificly
platelets disorders versus coagulation disorders.
Learn about the differential diagnosis of thrombocytopenia,
specifically thrombocytopenic purpura versus other platelet
disorders, such as thrombotic thrombocytopenic purpura
(TTP), hemolytic uremic syndrome (HUS), or disseminated
intravascular coagulation (DIC).
Learn about the treatment of ITP.
superficial petechiae and mucosal bleeding
disordered primarymary hemostasis
• complete blood count
• prothrombin time (PT)
• partial thromboplastin time (PTT)
• Bone marrow smear
APPROACH TO SUSPECTED
Medications: over-the-counter products (aspirin)
Family history of abnormal bleeding
History of epistaxis, menorrhagia, excessive prolonged
bleeding from minor cuts, bruising, prolonged or profuse
bleeding after dental extraction, excessive bleeding after
major surgery or obstetric delivery, trauma followed by
bleeding considered excessive relative to the injury
Timing of Bleeding
immediate and lasts for longer than 24 hours,a
problem with primary hemostatic plug formation
may be present. Therefore, this may suggest a
prolonged bleeding developed 2-3 days later, a
problem in the coagulation phase is suspected.
Type of Bleeding
Spontaneous mucus membrane bleeding, such as
gum bleeding, nose bleeding, and petechiae are
suggestive of a vascular disorder, thrombocytopenia,
or abnormal platelet function.
Hemarthrosis, deep hematoma, and retroperitoneal
bleeding are more likely to reflect a severe
• such as hemophilia, if problems have been lifelong
• spontaneous inhibitor of factor VIII, if problems appear later
• present with bleeding from mucus membranes and the
appearance of petechiae
• but usually the platelet count and the coagulation profile
(PT and PTT)are normal
Hereditary hemorrhagic telangiectasias
• inherited as an autosomal trait of high penetrance.
• the most common hereditary vascular disorder
Causes of thrombocytopenia
decreased platelet production
decreased platelet survival
This is generally a result of platelet dumping after
drawing blood into the anticoagulant ethylene
diamine tetra acetate (EDTA) .
• Identifying platelet aggregates on peripheral blood
• Using citrate or heparin as an anticoagulant
Impaired platelet production
Infiltration caused by malignancy or
Decrease platelet survival
immune thrombocytopenia purpua (caused by IgG antibody
against the platelets),
drug-induced thrombocytopenic purpura
lupus,infection with human immunodeficiency virus type 1)
Disseminated intravascular coagulation
hemolytic uremic syndrome
• early childhood
• antecedent upper respiratory infection
• self-limiting, usually resolves spontaneously within 3-6
• in adults, most likely to occur in women ages 20-40
• an insidious or subacute present.
• persist for months to
Several immunologic disorders
may mimic true ITP
drug induced thrombocytopenic purpura
• Discontinuation of the medication should lead to
improvement in the platelet count within a time frame
consistent with the drug’s metabolism.
• Many drugs are blown to cause thrombocytopenic
purpura, such as quinidine and quinine, Sulfonamide,
heparin, and gold compounds.
Nonimmunologic disorders may
mimic true ITP
• Secondary to some other process: sepsis, trauma,
metastatic malignancy, obstetric causes
• can be relatively mild indolent course, or severe llfethreatening process;
• ongoing coagulation and fibrinolysis;
• can cause thrombosis or hemorrhage;
• consumption of coagulation factors is seen as prolonged
PT and PTT
• Treatment aimed at underlying cause.
• If clotting,consider anticoagulate with heparin.
• If bleeding, replace factors and fibrinogen with
fresh frozen plasma or cryoprecipitate.
• Multiple causes, many seemingly trivial drugs/infection
lead to endothelial injury and release of von Willebrand
factor, triggering formation of mlcrovascular thrombi.
• altered mental states
• Microangiopathic hemolytic anemia
• Renal failure
excess/abnormal vWF), most patients
• Antiplatelet antibody leading to platelet destruction
• Children:following a Viral illness with resolution.
• Adults:a more indolent course with progression and
rarelys spontaneous resolution.
• Isolated thrombocytopenia, normal PT, PTT.
• Increased megakaryocytes on bone marrow aspiration.
• Oral Corticosterolds,
• Splenectomy if resistant to steroids,
• Intravenous Immmoglobulin
Most likely diagnosis:
• Immune thrombocytopenic purpura
Best initial treatment:
• Oral corticosteroids
A 50-year-old man has been treated for rheumatoid
arthritis for many years. He is currently taking
corticosteroids for the disease.On examination, he has
stigmata of rheumatoid arthritis and some fullness on his
left upper abdomen. His platelet count is slightly low at
56,000/mm3. His WBC count is 3,100/mm3 and Hgb
9.Og/dL. Which of the following is the most likely etiology
of the thrombocytopenia?
• A.Steroid induced
• C.Rheumatoid arthritis autoimmune induced
• D.Prior gold therapy
A 30-year-old woman with ITP has been taking
maximum corticosteroid doses and still has a
bleeding episodes. Which of the following should
she receive before her splenectomy?
• A.Washed leukocyte transfusion
• B.Intravenous interferon therapy
• C.pneumococcal vaccine
• D.Bone marrow radiotherapy
primary hemostatic problems (platelet plug at
(creation of a stable fibrin clot).
Disorders of secondary hemostasis (coagulation factor
deficiencies such as hemophilia)are usually characterized by
the development of superficial ecchymoses,as well as deep
hematomas and hemarthroses.
ITP is a diagnosis of exclusion.Patients have isolated
systemic lupus erythematosus, HIV or medication-induced
thrombocytopenia, and normal to increased numbers of
megakaryocytes in the bone marrow.
Treatment of ITP
• Corticosteroids are the initial treatment of ITP.
• Patients with more severe disease may be