1. IDOPATHIC THROMBOCYTOPENIA PURPURA
April Alexander

2. Diagnosis of ITP
ITP is an autoimmune bleeding disorder which is characterized by abnormally low level of platelets
1735 – Paul Gottlieb Werlhof
(Dameron & Puzanov, 2012) (Cines & Leibman, 2009) (

3. Diagnosis of ITP American society of hematology
History: Isolated bleeding symptoms in conjugation with thrombocytopenia without constitutional symptoms
PE: Signs of bleeding in the absence of hepatosplenomegaly, lymphadenopathy, or other congenital conditions.
Diagnostic tests:
CBC
Platelet count below 100,000 mcL
Normal RBC + WBC
Peripheral blood smear:
Platelets should be normal to large in size
Normal RBC + WBC (American Society of Hematology, 2011)

4. Pathogenesis
Antiplatelet antibodies begin to bind to the plasma membrane on platelets; as a result, platelet destruction by mononuclear phagocytes in the spleen occurs. The rate of platelet destruction happens so rapidly that it exceeds the bone marrows ability to produce more.
Secondary ITP has been linked to a viral illness especially in children
Autoimmune diseases
Genetics
(Johnsen, 2012)(

5. Clinical Manifestations
History:
Spontaneous bruising
Hemorrhagic bullae of the mucous membrane/gingival bleeding
Prolonged bleeding from minor injury
Epistaxis
Heavier than normal menstrual bleeding
Dark urine + stool
Important questions to ask:
Recent illness, recent hospitalization or surgery, medication list, travel history, blood disorders, leukemia, or autoimmune disorders

6. Review of systems General: fevers? Weight loss? Night sweats?
Skin: spontaneous bruising? swollen lymph nodes?
HEENT: Change in vision or hearing?
GI: Rectal bleeding? Dark stool?
Urinary: Dark urine?
Genital: Females- amount of menstrual bleeding?
Musculoskeletal: Bone pain?
Neurological: Changes in orientation, attention, or memory? Headaches? Dizziness?

7. Clinical Manifestations
Physical Exam:
Patients are going to feel well
petechiae, purpura, and ecchymosis on arms, legs, and trunk
Hemorrhagic bullae/gingival bleeding
Tympanic membrane hemorrhage
Retinal hemorrhage
Dried blood in nose from epistaxis
Vaginal and rectal exam may reveal bleeding
WNL
Afebrile, Lymph nodes, spleen, liver, no change in mentation

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10. Diagnostic tests CBC Platelet count below 100,000 mcL Normal RBC + WBC
Peripheral blood smear:
Platelets should be normal to large in size
Bone Marrow Aspiration
Megakaryocytes in normal or increased numbers
Urinalysis
Microscopic hematuria
HIV + HCV
H. Pylori (American Society of Hematology, 2011)

11. Differential Diagnosis
Von Willebrand Disease
Henoch Scholien Purpura
Acute Leukemia
Aplastic Anemia

12. Treatment Observation (monitored by Hematologist)
First line therapy for patients with platelet count <30,000 mcL
Corticosteroids
Prednisone mg/kg/day x 4 weeks
IVIg
Anti-D
Second line
Adults: splenectomy, Rituximab, Thrombopoetin Receptor Agonist
Children: splenectomy, Rituximab, high dose Dexamethasone
(American Society of Hematology, 2011)

13. High-does Dexamethasone vs Prednisone for treatment of adult ITP(

14. Patient Education Avoiding injury, NSAIDS, + Aspirin
Children are going to need to avoid contact sports until disease resolution
(Frey & Oberleitner, 2011)

15. Outcomes 80% of patients with acute ITP will make a full recovery
Most patients diagnosed with chronic ITP will achieve long term remission

16. References
American Society of Hematology. (2011). Retrieved from
Cines, D.B., & Leibman, H.A. (2009). The Immune thrombocytopenia syndrome: A Disorder of diverse pathogenesis and clinical presentation. Hematology- Oncology Clinics of North America, 23(6), doi: /j.hoc
Dameron, A., & Puzanov, I. (2012). Idiopathic thrombocytopenia purpura. In. H.B. Hawley (Ed.), Infectious disease and conditions (Vol. 2, pp ). Salem, MA: EBSCO Publishing Inc. Retrieved from
Dexamethasone tablet. [online image]. Retrieved April 26, 2016 from
Frey, R.J., & Oberleitner, M.G. (2011). Idiopathic Thrombocytopenia Purpura. In. L.J. Fundukian (Ed.), Gale encyclopedia of medicine, (Vol 3(4) pp ). Detroit, MI: Cengage learning. Retrieved from
Hemorrhagic bullae. [online image] Retrieved on April 25,2016 from
Idiopathic thrombocytopenia purpura. [online image] Retrieved on April 25, 2016 from
Johnsen, J. (2012). Pathogenesis in immune thrombocytopenia: New insights. American Society of Hematology education book, 1, Retrieved from
Petechiae. [online image]. Retrieved on April 25, 2016 from
Prednisone tablet. [online image]. Retrieved April 26, 2016 from
Thrombocytopenia. [online image]. Retrieved on April 26, 2016 from
Yu, W., Xue-bin, J., Ya-wen, W., Jing-xia, W., En-qin, Y., Zheng-cheng, W., Yu-qi, S., Zuo-mu, B., Cui-ai, R., Fang, Z., Guo-qiang, L., Jun, P., & Ming, H. (2016). High-dose Dexamethasone vs Prednisone for treatment of adult immune thrombocytopenia: A Prospective multicenter randomized trial. Blood, 127(3), doi: /blood