Severe

Thrombocytopenia:
Three VA cases
Sarah Walter, M.D.
 Thrombocytopenia
 Thrombocytopenia is defined as a platelet
count of < 150,000/ μL
 Due to:
 Increased destruction
 Sequestration
 Decreased production
 Thrombocytopenia
 Systematic approach to evaluating patients:
 History (associated illness, drugs, specific symptoms)
 Physical exam (anomalies, hepatosplenomegaly,
infection, tumor, lymphadenopathy, bleeding)
 Careful interpretation of the complete blood count and
examination of peripheral smear
• If diagnosis not made, consider bone marrow examination
with needle aspiration and biopsy
Case 1
 Case 1
 49 year old female who presented to the
Dermatology clinic with a petechial rash on her
legs. She denied vaginal or mucosal bleeding.
 History of depression and PTSD treated with
ziprasidone, trazadone, vanlafaxine,
clonazepam. And she recently started
carbamazepine 2 weeks prior.
 Case 1
 Pre-drug lab values (2  Laboratory data at time
weeks ago): of visit:
 WBC: 6.5 x 1000/μL (4.5 –  WBC: 4.6 x 1000/μL (4.5 –
11.0) 11.0)
 RBC: 3.9 M/μL (4.6 – 6.2)  RBC: 4.45 M/μL (4.6 – 6.2)
 Plt: 272 x 1000/μL (150 –  Plt: 3.32 x 1000/μL (150 –
400) 400)
 Hgb: 12.2 g/dL (14.5 –  Hgb: 12.6 g/dL (14.5 –
18.1) 18.1)
 Hct: 35.2% (42 – 54)  Hct: 39.5% (42 – 54)
 MCV: 90.4 fL (80 – 100)  MCV: 88.9 fL (80 – 100)
 MCH: 31.3 pg (28 – 34)  MCH: 28.4 pg (28 – 34)
 RDW: 12.7% (11.5 – 14.5)  RDW: 12.8% (11.5 – 14.5)
 Case 1
 Additional pertinent laboratory data:
 PT: 11.9 sec (10.8 – 13.7)
 aPTT: 19.9 sec (21.6 – 34.2)
 Occult blood: Positive
 UA: Negative for blood
 Fe: 93 μg/dL (35 – 145)
 TIBC: 314 μg/dL (275 – 400)
 Ferritin: 133 ng/mL (25 – 180)
 Case 1
 Smear:
 Case 1
 Differential diagnosis:
 Drug-induced thrombocytopenia
 ITP
 Infectious (viral)
 TTP
 DIC
 Case 1
 Carbamazepine was discontinued.
 Pt. received 1 unit of platelets (post-
transfusion count: 13.3
 1 week following, platelet count 383.
 Case 1
Diagnosis:
 Drug-induced thrombocytopenia:
 The main differential diagnosis in a drug-
induced thrombocytopenia is ITP.
 Drug exposure is the cause of 5-20% of
thrombocytopenias
 Typically see the effect approximately 14 days
after starting the medication
Drug-Induced Thrombocytopenia
 Mechanism of various blood dyscrasias
due to drugs:
 Interference with hematopoiesis, bone marrow
suppression
 Drug induced antibodies
 Commonly seen with the psychotropic drugs,
quinidine, sulfonamides, and gold
• Study by Stübner et al (2004), found that clozapine
was most common psychotropic drug to cause
blood dyscrasias (0.18%) followed by
carbamazepine (0.14%).
Drug-Induced Thrombocytopenia
 Mechanisms of drug-dependent antibody
formation:
 Accelerated platelet destruction due to drug-
dependent antibody
• Reversible drug binding to one of the platelet surface
glycoproteins (GP Ib/IX, GP IIb/IIIa) causing conformational
change, resulting in the exposure of a neoepitope, expressed
by a sequence that is normally concealed within the
hydrophobic domain of the protein.
• Molecular structure of the drug becomes an integral part of
the new antigenic epitope
 There are no good laboratory tests to detect these
drug-induced antibodies.
Drug-Induced Thrombocytopenia
 Criteria to make diagnosis:
 1) Candidate drug preceded thrombocytopenia AND
recovery from thrombocytopenia was complete and
sustained after the drug was discontinued.
 2) The candidate drug was the only drug used prior to
the onset of thrombocytopenia OR other drugs were
continued or reintroduced after discontinuation of the
candidate drug with a sustained normal platelet count.
 3) Other etiologies for thrombocytopenia were excluded.
 4) Reexposure to the candidate drug resulted in
recurrent thrombocytopenia.
 Definite (Level 1): meet criteria 1, 2, 3, 4
 Probable (Level 2): meet criteria 1, 2, 3
Drug-Induced Thrombocytopenia
 Thrombocytopenia associated with
carbamazepine usually appears 14 to 16 days
after initiation of drug. The platelet count
completely resolved in all cases 7 days after
after the drug was discontinued.
 Gold induced thrombocytopenia doesn’t follow
this pattern, have persistently low platelets for
months because of prolonged retention of gold
salts
Case 2
 Case 2
 24 year old African American female
presented with complaints of:
 Easy bruising x 1 month
 Heavy menses
 1-2 episodes of fever in the past month
 2 days of cervical lymphadenopathy
(resolved)
 Occasional night sweats
 No weight loss
 Case 2
 Initial laboratory findings:
 WBC: 3.15 x 1000/μL (4.5 – 11.0)
 RBC: 3.26 M/μL (4.6 – 6.2)
 Plt: 3.16 x 1000/μL (150 – 400)
 Hgb: 8.80 g/dL (14.5 – 18.1)
 Hct: 26.7% (42 – 54)
 MCV: 81.8 fL (80 – 100)
 MCH: 27.0 pg (28 – 34)
 RDW: 16.1% (11.5 – 14.5)
 Abs Neutrophil: 1.63 x 1000/μL (1.8 – 7.8)
 Case 2
 Smear
 Case 2
 Differential diagnosis of pancytopenia with
severe thrombocytopenia:
 Marrow infiltrative process (i.e. leukemia,
lymphoma, metastatic disease)
 Idiopathic Thrombocytopenic Purpura (ITP)
• Why the neutropenia and anemia?

 Next step, bone marrow biopsy.

 Case 2
Diagnosis:
 ITP
 Iron deficiency anemia, secondary to
menometrorrhagia from low platelets
 Benign neutropenia of African Americans
 Low absolute neutrophil count seen in African
Americans. No increased risk of infection.
 Case 2
 Patient received steroids, IVIG x1, platelet
transfusions.
 1 week following, repeat CBC with a platelet
count of 35
 ITP
Epidemiology of ITP:
 Incidence of 3-5 per cases 100,000
persons
 Onset typically adults aged 20-40 years
 Female predominance
 ITP
 Differential diagnosis:
 Diagnosis of exclusion, need to exclude drug-induced
thrombocytopenia
 Familial thrombocytopenia
• Check family history of low platelets unresponsive to
treatment for ITP
 HIV-ITP
 Thrombotic thrombocytopenic purpura (TTP)
 Spurious thrombocytopenia resulting from platelet
clumping
• Always look at the peripheral smear of a patient with
thrombocytopenia
 ITP
 Mechanism:
 Patients platelets are coated with IgG antibodies the
recognize the platelet surface glycoproteins. Tissue
macrophages recognize the Fc receptor, and
phagocytose the platelet-AB complex.
 May also have reduced megakaryocyte production
secondary to autoantibodies against megakaryocytes.
 Most frequent target antigens include GP Ib/IX/V and
GP IIb/IIIa
 ITP
Diagnosis:
 Diagnosis of exclusion
 Should exclude other causes of thrombocytopenia
 Review the peripheral smear
 Bone marrow examination if atypical
 Detection of anti-platelet antibodies(49-66%
sensitive, 78-92% specific, interlaboratory agreement
55-67%) (not readily used)
 Flow cytometry to detect platelet associated
autoantibodies (still being investigated but may be
promising)
 ITP
 Diseases and disorders associated with ITP:
 HIV
• Circulating immune complexes may nonspecifically deposit on
platelet membrane, and are then cleared from system
• Direct infection of megakaryocytes by HIV infection impairs
platelet production
 Hepatitis C
 ?? H. pylori (still being debated)
• Thought is that some strains of H. Pylori express the Lewis (Le)
antigen. The Le antigen may adsorb the the platelet surface and
serve as a target for anti-Le antibodies.
 SLE
• The patient had elevated ANA titer (1:2500) (still to be worked up)
 ITP
Treatment:
 Steroids
 Anti-D
 Use in Rh+ patients. The Anti-D will coat the patient’s
RBC, so that the IgG coated RBC compete with the
IgG coated platelets for phagocytosis from the spleen,
blocking splenic destruction of platelets.
 IVIG
 Splenectomy if refractory to treatment
Case 3
 Case 3
 76 year old male with 80-90% stenosis of
left main coronary artery, 70% stenosis of
left anterior descending coronary artery
 Underwent Coronary Artery Bypass Graft
(CABG)
 Case 3
 Platelet counts:
 Pre-op: 169 x 1000/μL (150 – 400)
 Day of surgery: 110
 POD #1: 104
 POD #2: 74.7
 POD #3: 92.2
 POD #4: 81.5
 POD #5: 89.8
 POD #6: 52.3
 POD #7: 11.3
 POD #8: 8.86
 Case 3
 Patient received heparin prior to and
during surgery, with no documentation of
heparin received post-operatively.
 No clinical evidence of clotting.
 Case 3
 Differential diagnosis:
 Heparin-induced thrombocytopenia (HIT)
 Other drug-induced thrombocytopenia
 ITP
 DIC
 TTP
 Case 3
Diagnosis:
 Heparin-induced thrombocytopenia
 ELISA test positive
 Case 3
 Patient was switched to Argatroban, all
heparin was discontinued
 Platelet count increased to 231
 No thrombotic events
 HIT
 Occurs as a result of an antibody complex
between heparin and platelet factor 4
 IgG antibodies bind to the platelet Fc
receptor and cause platelet activation,
resulting in platelet activation as well as
clearance from circulation.
HIT
 HIT
 Diagnosis:
 Diagnosis rests primarily on clinical grounds
• Laboratory tests not always locally available.
• Lab tests may not be available in timely manner
• Available tests are not completely sensitive or
specific.
 HIT
Clinical diagnosis (Four T’s):
 Thrombocytopenia: >50% fall in platelet count
 Timing: Days 5-10 after exposure to heparin, or
<day 1 with recent heparin exposure (past 30
days)
 Thrombosis: Proven new thrombosis; skin
necrosis; acute systemic reaction after IV
heparin
 OTher causes of platelet fall excluded
 HIT
 Functional assay:Utilize the ability of the
antibody to cause platelet activation as an
endpoint.
 Require source of normal human platelets
with variability
 See platelet activation at therapeutic
concentration of heparin, but not at markedly
therapeutic levels
 HIT
 Functional assays:
 Serotonin release assay. Most sensitive and specific of
the functional assays
• Incubate washed platelets with radiolabeled serotonin.
Metabolically active platelets tae up serotonin and store it in their
granules.
• “Hot” platelets incubated with patient’s serum in the presence and
absence of heparin at therapeutic and supratherapeutic levels.
• Measure radioactivity in supernatant. Positive if:
 >20% release at therapeutic heparin level
 <20% release at supratherapeutic levels
• 99% specificity, high sensitivity
• Very few labs perform because of technical difficulty and use of
radioactive substances.
 HIT
 Functional assays:
 ATP release via luminescence aggregometry
• Closely resembles SRA as alternative approach
• Able to detect ATP release of activated platelets
 Platelet aggregation studies:
• Donor platelets incubated with patient’s serum and heparin.
Measure donor platelets aggregation without heparin, with
therapeutic levels of heparin, and with supratherapeutic
heparin
• Highly dependent on donor platelets
 Sensitivity 39-81%
 Specificity 82%
 HIT
 Immunological Assays:
 ELISA to detect the Heparin-PF4 antibody
• Does not require normal platelets, technically
easier to perform
• High false positive rate, low specificity
 50-60% patients undergoing open heart surgery will have
a positive ELISA in the absence of clinical HIT
 Commercially available assay detects IgG, IgA, and IgM
heparin-PF4 antibodies
• Unlikely that IgM would cause clinical disease
 HIT
 Immunologic Assays:
 ELISA (cont’d):
• Does have higher sensitivity than aggregation
studies
 ELISA for HIT may initially be negative at time first
clinically suspect HIT, but that a portion of those may
then develop a positive ELISA if the test is repeated
based on persisting clinical suspicion.
 May have false negative because HIT is due to an
antigen other than PF4
 HIT
 No laboratory test is 100% specific or
sensitive for HIT
 Interpret results in light of the pretest
probability. Should only be performed
when there is a clinical indication of HIT
 HIT
 Treatment:
 Discontinue all heparin and low molecular
weight heparin
 Use alternative anticoagulant (direct thrombin
inhibitor):
• Argatroban
• Lepirudin
The End