1. An unusual case of Menorrhagia in a young girl
Dr.Manoj Prakash.J JR-II
Dept of Medicine

2. HISTORY A 16 Yrs old female patient came to casulty
c/o massive Per vaginal bleeding since 15 days.
She also complained of giddiness and breathlessness on exertion
since 3 yrs
She gave h/o-recurrent episodes of menorrhagia for the past 3 yrs

3. PAST HISTORY
She was diagnosed as ITP in 2007 when she presented with epistaxis
She attained menarche in 2015 , cycles were irregular
With menorrhagia for 10–13 days during each cycle
Received –PCV transfusions , inj methylprednisolone and Tab Danazol and Tab Azathioprine and Vincristine (but no improvement )
Adv - splenectomy and inj rituximab in 2016 (not done).

4. GENERAL EXAMINATION
Afebrile, Pulse – 110/min BP /60 mmHg
RR - 22/min SpO % on room air
PALLOR + + +
SYSTEMIC EXAMINATION
P/A :Soft
spleen palpable -1.5 cms below the left costal margin , non- tender
Hepatomegaly was present .extending 2.5 cms below costal margin
Other systems examination - normal

5. LAB PARAMETERS - HB – 5.4g% TLC-6000 (39/57/2/2)
Platelet counts – 9800/cumm
MCV-70.2
Retic count-1.2%
PBS – Microcytic , hypochromic RBCs with Target cells and Tear drop cells
Direct Coombs Test & Indirect Coombs Test - Negative
INR – 1.21 ; APTT – 24.9
LFTS/RFT/S.E/URINE r/m-WNL
Dengue/HIV/HBsAg-negative

6. CHRONIC IMMUNE THROMBOCYTOPENIC PURPURA WITH
In view of history , general and systemic examination with basic investigations, our diagnosis was –
CHRONIC IMMUNE THROMBOCYTOPENIC PURPURA
WITH
MICROCYTIC ANEMIA DUE TO BLOOD LOSS

7. Treatment PCV transfusion , SDP and RDP transfusions
Tab. Prednisolone 40 mg od
OBGY Ref – Tab Norethinsteron 5mg started
Inspite of the transfusions and steroids her platelet count continued to stay less than 10000/cu.mm
And bleeding PV continued
Further investigations were done

8. ANA – Negative TFT – WNL Anti HCV – Positive (by ELISA) HCV Genotype (NIV) – Genotype “1 A” HCV RNA Viral Load - > Repeat platlet counts <20000/cu.mm

9. The patient was started on
Tab. Sofosbuvir + Ledipasvir (400/90) od for 12 weeks
Tab. Prednisolone 40 mg od and then tapered off
Tab. Norethinsterone 5mg od
F/U with HCV Viral Load and complete blood count was advised after 12 weeks.

10. After 12 weeks- Hb-9.2mg/dl Platelet counts – 98000/cumm HCV RNA was not detected by RT-PCR The patient has been weaned off from steroids and has regular periods now

11. IMMUNE THROMBOCYTOPENIC PURPURA(ITP) WITH HEPATITIS C
It is an acquired disorder in which there is immune-mediated destruction of platelets and possibly inhibition of platelet release from the megakaryocyte.
In children - it is usually an acute disease, most commonly following an infection, and with a self-limited course.
In adults - it is a more of a chronic disease.
It is termed secondary if it is associated with an underlying disorder like - autoimmune disorders (particularly SLE), and infections such as HIV and hepatitis C, are common causes.

12. Hepatitis C association with ITP is quiet prevalent (1,5)
According to reviewers it is not yet clear whether there is a ‘cause-effect’ relationship(2,3,6,7)
However , in some cases Researchers achieved a good control of thrombocytopenia , after treatment of HCV
Hence we decided to treat our patient for HCV
And so far the platelet count has remained in the range of 90,000 to 1 lac .
And patient has not had menorrhagia

13. TAKE HOME MESSAGE
In every case of Immune Thrombocytopenic Purpura, do look for other causes of Immune mediated Thrombocytopenia , especially Hepatitis C Virus infection.

14. REFERENCES
1)Paul Pockros,Andrea Duchini,Robert Macmillan,Lisa Nyberg “Immune thrombocytopenic purpura in patients with chronic hepatitis C virus infection”American Journal Of Gastroenterology 97, (2002)
2) ,1 and 1Immunological HCV-Associated Thrombocytopenia: Short ReviewClinical and Developmental Immunology Volume 2012, Article ID 378653, 5 pages
3)Kenneth D. Flora, MD reviewing Pockros PJ et al.ITP in Patients with HCV.NEJM Journal Watch October
4)Subhash verma* shiva kumar,asish garg*,**pankaj malhotra “Hepatitis C Virus Infection Among Patients with Chronic Immune Thrombocytopenic Purpura in Northern India j clin exp
hepatol Sep; 1(2): 68–72.
5)LeMin Lee, MaxE Johansen, Wenche Jy, Lawrence L Horstman and Yeon-Soong Ahn.Second Generation Direct-Acting Antiviral Agents Eradicate Hepatitis C Virus (HCV) but Exacerbate Thrombocytopenia in a Patient with HCV-Associated Immune Thrombocytopenic Purpura (ITP): Case Report Blood 2014 124:5022;
6)Yasser M Fouad Chronic hepatitis C-associated thrombocytopenia: aetiology and management Quarterly Reviews Tropical Gastroenterology