A Case of Immune Thrombocytopenia

James B. Bussel, MD:This is the case of a 48-year-old woman with a not atypical presentation of ITP. She has minor bleeding symptoms—petechiae, purpura, and some nosebleeds—and is seen by her physician for that, who tends to dismiss it because the findings are not very pronounced.

He does, however, appropriately do a blood count, and that is normal, as is her physical examination and, in general, her history. But her platelet counts are 28,000 per microliter, when the lower limit of a normal platelet count would be 150,000 per microliter. On the one hand, he suspects ITP because she’s well and has no other findings and symptoms that are new to her. On the other hand, they’re not so severe and the count is not so low that she automatically requires treatment at this time.

She had taken occasional ibuprofen previously, and he counsels her not to do that because ibuprofen can interfere with platelet function and thus increase her degree of bleeding at a given platelet count. And while it is very unlikely that hydrochlorothiazide has anything to do with this, he counsels her to change to another antihypertensive medication just to make sure this is not drug-induced thrombocytopenia.

Even though her count is not very low, she feels uncomfortable. He starts her on a course of prednisone at approximately 1 mg/kg to try to increase her count and to hope that the ITP will either go away or at least improve enough that she will not require any treatment. It’s, of course, debatable as to exactly at what count treatment should be initiated. In general, at a count of 30,000 or below in an adult, most people would initiate treatment. It could depend on when her last ibuprofen was, ie, how well are her platelets working. It could depend on her lifestyle or other comorbidities related to extra risks of bleeding. For example, what if she’s a construction worker? It could depend on whether she travels a lot and will be out of touch with medical care, so it would be safer to have her on treatment than not. Or it could depend on other factors such as degree of bleeding, which does not seem to be the one in this case. If she were older, say over 60 or 65, there would definitely be an increased risk of intracranial hemorrhage in the older age group, and that would be another reason to be more stringent about treatment.

Transcript edited for clarity.

Case: A 48-year-old woman presenting with unusual bruising

October 2017

• A 48-year-old woman presents with complaints of bruising after minor bumps, bleeding gums despite regular tooth cleaning, and a recent spontaneous bloody nose; symptom onset about 1 year ago
• Physical evaluation reveals a woman of normal weight and average height, afebrile, no splenomegaly
• No personal or family history of cancer, autoimmune disease; no recent viral illnesses; no bone pain or night sweats
• Current medications: ibuprofen as needed, generic hydrochlorothiazide (HCTZ)
• Laboratory findings:
  • CBC reveals platelets 28 X 10⁹/L
  • WBCs within normal
  • Renal and hepatic function within normal
• Diagnosis: idiopathic thrombocytopenic purpura
• Patient started on a course of prednisone 1 mg/kg for 21 days, then tapered off
  • Platelets: 29 X 10⁹/L
  • Second course of prednisone 1 mg/kg for 21 days

April 2018

• After 2 courses of prednisone, patient’s platelets have not recovered
  • CBC shows platelets at 28 X 10⁹/L
• Symptoms of easy bruising and bleeding from gums continue
• After discussion with patient, she is started on the thrombopoietin receptor agonist (TPO-RA) eltrombopag (PROMACTA), at a dose of 50 mg/day
  • Dose increased to 75 mg/day; last platelet count, 65 X 10⁹/L