APPROACH TO

THROMBOCYTOPENIA
DR. AHMED MAHDY – KBIM – R4
 OUTLINE
• Definitions
• When To Worry
• Approach to Thrombocytopenia
• History
• Physical Exam
• Lab Investigations
• Hematology Consultation
• Bone Marrow Evaluation
• Causes of Thrombocytopenia
• General Management Principles
 DEFINITION

1. Mild: 100 to 150

2. Moderate: 50 to 100
3. Severe: < 50

Keep in mind, these are 95% confidence intervals, so 2.5% of

population < 150
 WHEN TO WORRY ABOUT BLEEDING

• Presence of wet purpura

• Prior Bleeding episode at a similar Plt Number
• Clinical Judgment is essential to Determine A “safe” Level

Platelet Number Risk

<50 Bleeding from General Surgeries
Bleeding from High Risk Procedures (Neurosurgery, Ocular,
<100
Orthopedic, Cardiac)
<20 (mostly <10) Spontaneous Bleeding
 WHEN TO WORRY ABOUT THROMBOSIS

• Heparin Induced Thrombocytopenia (HIT)

• Antiphospholipid Syndrome (APS)
• Disseminated Intravascular Coagulation
• Thrombotic Microangiopathy (e.g. TTP or HUS)
• Paroxysmal Nocturnal Hemoglobinuria (PNH)
 APPROACH TO THROMBOCYTOPENIA

• History
• Prior platelet counts
• Family history of bleeding/thrombosis
• History of bleeding
• Drug history
• Exposure to infections
• Past medical conditions
• Diet
 APPROACH TO THROMBOCYTOPENIA

• Physical Exam
• Skin and other bleeding sites:
• Petechia
• Purpura
• Ecchymosis
• Hematuria
• Malena
• Liver
• spleen
• lymph nodes
 APPROACH TO THROMBOCYTOPENIA

• Lab Investigations (essential)

• Repeat CBC
• Immediately: symptomatic/clinical findings present
• Non-urgent: asymptomatic/out of context
• Peripheral blood smear
• Rule out psuedothrombocytopenia
• Abnormal WBC/RBC morphology
• HIV & Hep C
PERIPHERAL SMEAR IN THROMBOCYTOPENIA
• Schistocytes: a microangiopathic process (eg, DIC, TTP, HUS).

• Nucleated RBCs and Howell-Jolly bodies: post-splenectomy or occasionally in patients with poor splenic
function.

• Spherocytes: immune-mediated hemolytic anemia or hereditary spherocytosis.

• Leukoerythroblastic findings, teardrop cells, nucleated RBCs, or immature granulocytes: an infiltrative

process in the bone marrow.

• Leukocytosis with a predominance of bands (left shift) or toxic granulations: infection.

• Immature WBCs (eg, myeloblasts) or dysplastic WBCs: leukemia or myelodysplasia.

• Multi-lobed/hypersegmented neutrophils (i.e, >5 lobes): a megaloblastic process

(eg, B12/folate/copper deficiency)
 APPROACH TO THROMBOCYTOPENIA

• Lab Tests (Others, if indicated)

• Anti-nuclear antibodies or anti-phospholipid antibodies
• Hepatic enzymes, albumin
• PT, aPTT
• LDH
• Renal function Tests
 APPROACH TO THROMBOCYTOPENIA

• Hematology Consultation
• Urgent:
• TTP/HUS
• HIT
• Malignancy: Acute Leukemia, aplastic Anemia
• Severe thrombocytopenia: Bleeding, for urgent procedure, pregnancy
• Elective:
• confirm any new diagnosis of a thrombocytopenic condition
• to determine the cause of any unexplained thrombocytopenia after proper
work-up (e.g. for bone marrow evaluation)
 APPROACH TO THROMBOCYTOPENIA
• Bone marrow examination (aspirate and biopsy)
• Cause of thrombocytopenia is unclear
• Primary hematologic disorder is suspected
• Findings

• Normal or increased numbers of megakaryocytes: platelet destruction (eg, ITP, drug-induced immune
thrombocytopenia)
• Decreased megakaryocyte numbers, decreased or absent cellularity: aplastic anemia.
• severe reduction or absence of megakaryocytes: SLE, (an autoantibody directed against the
thrombopoietin receptor)
• Megaloblastic changes in the RBC and granulocytic series: nutrient deficiency (eg, vitamin B12,
folate, copper)
• Dysplastic changes: myelodysplastic disorder
• Granulomata, increased reticulin or collagen fibrosis or infiltration with malignant cells: bone
marrow invasion
APPROACH TO THROMBOCYTOPENIA
 CAUSES
Two Main Categories

1. Decreased production
• BM failure syndromes (eg, aplastic anaemia, myelodysplastic
syndromes, and chemotherapy-induced thrombocytopenia)
2. Increased destruction
• DIC and the thrombotic microangiopathies; together with platelet
sequestration and hemodilution less commonly
 CAUSES (CONT’D)
Bone Marrow Dysfunction
• MDS
• Leukemia
• Paroxysmal Nocturnal Hemoglobinuria
• Infection
• Alcoholism
• Nutritional Deficits
• ITP (decreased BM production and peripheral destruction)
• Malignancy (extension into BM)
 CAUSES (CONT’D)
1. Redistribution
a. Spleen carries ⅓ of our total body platelet mass
b. Hypersplenism redistributes this higher (ex: ½)
c. Total body mass is the same

2. Hemodilution
a. Platelet-poor transfusions (PRBC, fluids)
 CAUSES (CONT’D)
Destruction/Consumption
• Thrombotic Microangiopathies (TTP, Hus, DIC)
• Immune Thrombocytopenia
• Drug-Induced Thrombocytopenia
• Evan’s Syndrome
• Heparin Induced Thrombocytopenia
 DRUG INDUCED THROMBOCYTOPENIA (DIT)
Drug-induced Thrombocytopenia typically presenting 5-7 days after exposure to the causative agent, and resolving
between 7- 14 days after drug discontinuation.

• Penicillins
• Carbamazepine
• Gold compounds
• Heparin
• Phenytoin
• Rifampin
• Sulfonamides
• Linezolid
• Vancomycin
• Valproic Acid
• Etc…
 GENERAL MANAGEMENT PRINCIPLES
• Activity restrictions: 
• moderate to severe thrombocytopenia (<50,000/microL) generally should not participate in
extreme athletics such as boxing, rugby, and martial arts.
• Management of Anticoagulant and anti-platelet medications 
• Prophylactic anticoagulation at 30,000 or above
• Theraputic Anticoagulation requires higher figures (50,000)
• Over-the-counter drugs:
• Caution with drugs interfering with platelet function (eg, aspirin, non-steroidal anti-
inflammatory drugs, ginkgo biloba).
• Safe platelet count for invasive procedures 
• Emergency management of bleeding 
• bleeding with severe thrombocytopenia requires immediate platelet transfusion, regardless
of the underlying cause.
WHEN TO TRANSFUSE?
THANKS FOR LISTENING