Presenting With Immune Thrombocytopenia

James B. Bussel, MD:This case reflects a 44-year-old woman who has some issues with her ITP. One of the things that characterizes her is that she’s having heavy menses and she has been evaluated for this, though the details are not present. Another thing that characterizes her case is that she’s a little bit overweight, which usually makes patients relatively prednisone-averse because they know they will gain more weight and they’re already feeling overweight and wanting to lose weight. Otherwise, she does not have any other findings that could be associated with her ITP described. Her physician elected to test her for HIV and hepatitis C, which many people would recommend should be done in all patients, although it’s not clear how necessary it is and it’s not clear if that’s really done in general practice.

The interesting thing is she’s also tested forH pylori(Helicobacter pylori). The findings withH pylorion one hand have linked it to ITP and there definitely are a relatively large number of patients who, if they haveH pyloriand it’s eradicated with treatment, will then have their platelets go up. On the other hand, the great majority of those patients are in Italy and Japan, and in the United States, there’s not many patients for whom that has happened even if theirH pylorihas been eradicated. Finally, it’s not said how she was tested forH pylori. Antibody-based testing by drawing blood is a particularly poor way to do it with high false positive and false negative rates. So, if it’s done, it should either be by a breath test or by a stool antigen test, and we don’t know in her case how this happened.

Notwithstanding how she feels about steroids, she has received 3 courses of prednisone and likely gained at least another 20 pounds if she’s typical for most patients. And the question is when to initiate other treatment and what that other treatment should be. Many people would have said she shouldn’t have received the second and third course of prednisone because of the many side effects of steroids. It’s an interesting debate. There have been 2 recent articles suggesting that we have overdone not doing splenectomy, meaning that too few splenectomies are done and that we should do more of them. And there are reasons for that. So, if somebody asked, “What if we just did a splenectomy in this woman as her primary second-line option after, say, 4 to 6 months of prednisone used intermittently, would this be appropriate or would this be worse than other regimes?”, the short answer would be that that’s a perfectly appropriate management scheme. Because even adults with ITP may tend to get better. Most people recommend however, even if you think splenectomy is a good thing, to wait for at least a year unless there’s a special reason to do it sooner.

Transcript edited for clarity.

Case: A 44-year-old woman presenting with reddish-purple rash on lower legs

February 2017

• Patient presents with complaints of a reddish-purple rash on her lower legs and “constant” bruises appearing “spontaneously” without her remembering any trauma
• Physical evaluation reveals:
  • The rash to be petechiae (subcutaneous bleeding)
  • Slightly overweight (BMI = 26.5 kg/m²)
  • Patient is afebrile, with no splenomegaly
• When asked, reports her menstrual flow is unusually heavy, but says she was evaluated for and had no evidence of fibroids or endometriosis
• No personal or family history of cancer; no recent viral illnesses; no bone pain
• Current medications: no chronic medications; acetaminophen as needed; multivitamin
• Laboratory findings:
  • CBC reveals platelets 21 X 10⁹/L
  • All other findings with normal range
  • Negative forH pylori, HIV, and HCV
• Diagnosis: chronic ITP
  • Started course of prednisone 1 mg/kg X 21 days, then tapered off; at evaluation, platelets: 27 X 10⁹/L
  • Second course of prednisone 1 mg/kg X 21 days; at evaluation, platelets still <30
  • Third course of prednisone 1 mg/kg X 21 days; at evaluation, platelets still <30

February 2018

• &ldquo;Rash&rdquo; partly resolved, bruising still present
• Patient complains of weight gain on treatment and trouble sleeping
• After discussion with patient, she is started on eltrombopag (PROMACTA), at a dose of 50 mg/day