Question of the week # 285

285) A 26 year old man is seen in the office because he was found to have abnormal blood counts during a health check up prior to his life insurance application. He says he was told to see his physicians because his platelet count was very low. He denies any easy bruising, nose bleeding or any other gross bleeding. He has no other medical problems. He denies smoking , alcohol or drug abuse. He denies any recent infections. He leads a very active lifestyle and is a professional soccer player. He proudly states that he won his team the state level championship a year ago and likes to aggressively pursue this career. Physical examination  is benign. There is no splenomegaly. Repeat aboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in managing this patient?

A) Intavenous Immunoglobulin

B) Recommend against soccer for life

C) Splenectomy

D) Observation

E) Prednisone

10 Responses

  1. D……A platelet count below 20,000 per μl is generally an indication for treatment. Patients with a count between 20,000 and 50,000 per μl are usually evaluated on a case-by-case basis, and, with rare exceptions, there is usually no need to treat patients with a count above 50,000 per μl. In this case with 45 per μl of platelet, I will observe the patient. Others doctors will start with prednisone..

  2. eee

  3. D: I will observe this pt

  4. the most important cause of ITP is immune mediated.thats y in my opinion patient requires immunosuppressive therapy i.e,prednisone

  5. Just D, you won’t do corticosteroid therapy – or any immunosoppressive drugs – just because of this low plts count, maybe if he will show up with petechiae, or beeding problems (that he denies) we’ll think to do such therapy. Furthermore, seeing that he likes to be a soccer player, and that he’s a very young man I will probabily try other therapies before corticosteroid… Why not splenectomy in this case? He’s young, he’s athletic, he can undergo surgery and be fine

    • Hi Gadmoz, Many patients with ITP May have very good and durable responses with steroids thereby, allowing you taper off steroids. Therefore, steroid should be used first before considering invasive steps such as Splenectomy. Splenectomy is reserved for Steroid refractory patients or in those who steroids are contraindicated.

  6. D) Patient is asymptomatic. Therapy with prednisone should be initiated when the patient exhibit symptoms related to thrombocytopenia. Splenectomy is reserved for patients who experience relapse when glucocorticoid therapy is tapered

  7. will observe the patient

  8. Dr, Red —what is u r ans????

  9. Some patients with platelet counts >30,000/microL may require treatment if they have an increased risk of bleeding (eg, peptic ulcer disease, high risk of falling); other hemostatic defects (eg, use of antiplatelet agents or anticoagulants); a history of bleeding at a higher platelet count; or a need for surgery/invasive procedures . For some patients, maintaining the platelet counts >50,000/microL may be desirable because of lifestyle (eg, active sports) or occupation.

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