CASE REPORT

IMMUNE THROMBOCYTOPENIC
PURPURA

BY
dr FELIN APRILAINELD NDU UFI

SUPERVISOR :
dr. LAILATUL FITRIYAH, SP.PD
 INTRODUCE

Known as Autoantibody
idiopathic destroyed
thrombocytopenic trombosite
purpura premature
Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med. 2017;6(2):16. Published 2017 Feb 9. doi:10.3390/jcm6020016
 TYPE

Kistangari G, McCrae KR. Immune thrombocytopenia. Hematol Oncol Clin North Am. 2013;27(3):495-520. doi:10.1016/j.hoc.2013.03.001
Pathophysiology
Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med. 2017;6(2):16. Published 2017 Feb 9. doi:10.3390/jcm6020016
Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med. 2017;6(2):16. Published 2017 Feb 9. doi:10.3390/jcm6020016
Kistangari G, McCrae KR. Immune thrombocytopenia. Hematol Oncol Clin North Am. 2013;27(3):495-520. doi:10.1016/j.hoc.2013.03.001
DIAGNOSE
 DIF DIAGNOSE

Kelton JG, Vrbensky JR, Arnold DM. How do we diagnose immune thrombocytopenia in 2018?. Hematology Am Soc Hematol Educ Program.
2018;2018(1):561-567. doi:10.1182/asheducation-2018.1.561
TREATMENT
Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med. 2017;6(2):16. Published 2017 Feb 9. doi:10.3390/jcm6020016
Case
 HISTORY
SEPTEMBER 6TH 2020

FEVER
 IDENTITAS
• NAME : MRS MB
• SEX : FEMALE
• BIRTH : KUAFEU, AUGUST 18TH 1989
• AGE : 31 YO
• ADDRESS : BOKING
• DO : FARMER
• INPATIENT : SUNDAY, SEPTEMBER 6TH 2020. 6 PM
 HISTORY

• FEVER 6 HOURS BEFORE

• AND EPIGASTRIC PAIN
• DIARRHEA 3X/DAY IN 2DAYS, BLOOD(-)
• HER APPETITE WAS DOWN AND SHE BECAME WEAK AND FATIQUE.
• MENSTRUATION WAS 3 YEARS AGO AFTER GET CONTRACEPTION
• PAST MEDICAL TREATMENT ( -)
• PAST ILLNESS (-)
• ALLERGY (-)
• FAMILY’S DISEASE (-)
 PHYSICAL EXAMINATION

ADULT WARD, SUNDAY SEPT 6TH 2020

W : 58 KG
GCS : E4V5M6 H : 159 CM
BP : 107/65 MMHG
HR : 100X/MENIT
RR : 22X/MENIT
T : 37,2 C
SPO2 : 99%
 PHYSICAL EXAMINATION
 HEAD : NORMAL
• EYE : ANEMIS-/-, JAUNDICE -/-
 NOSE : NOSEBLEED -/-
+ + - - - -
 THORAKS : L : VESIKULER
+ + RONKHI WHEEZING
- - - -
+ + - - - -
H: S1-2 SINGGLE REGULER, MURMUR (-) GALLOP(-)
 STOMACH : SUPEL, BS (+) NORMAL, MASS(-), TENDERNESS EPIGASTRIA(+)
 PHYSICAL EXAMINATION
 HF :WARM, CRT <2SEC, OEDEMA(-)
 SKIN : PURPURA (-), HEMATOMA (-), RUMPLE LEED TEST(+)
 LABORATORY TEST
06/09/2020
UT:
• HB: 11,0 G/DL LEUKOCYTE : +1
PROTEIN +1
• HT: 33,6 %
PH 6
• WBC :14,6 10³/UL BLOOD : +3
• PLATELETS : 27 10³/UL SEDIMENT:

• DIFF COUNT: ERYTHROCYTE : 30-35/HPF

• LIMPHOCYTES : 5,8 % L EPITHELIAL SQUAMOS CELL : +

• MID : 7 % L LEUKOCYTE : 5-6 /HPF

• GRANULOCYTE : 87,2 H URIC ACID CRISTAL : +

BACTERIA :+2
 • Obs Febris H1 ec Dengue Fever dd DHF

Diagnosis • Susp ISK

(IGD)
• IVFD RingerLaktat 20 tpm
• Inj : Ceftriaxon 2x1 gr IV (ST)

Tatalaksana Inj omeprazol 2x40mg IV

•
• Inj Ondacentron 3x4mg IV
• Paracetamol 3x500mg po
• GG 3x100mg po
• R/ Cek Urinalisis
 07/09/2020
• S : Nyeri perut atas (+), demam ↑↓
• O : TD : 125/79 N : 87x/m RR: 20x/m
S: 36,9
• Abdomen NTE (+),NTH S/D +/+
• A: Susp ITP + ISK + BSK
• P Tx:
• Diet Lunak 1800 kkal
• IVFD RL 30tpm
• Inj Omz 2x40mg iv
• Inj ondancentron 3x4mg iv
• Inj Asam Tranexamat 3x500mg iv
• Inj Ceftriaxone 2x1 gr iv
• Paracetamol3x500mg po pc
• Batugin Syr 3xCI pc
• Imunas Cafs 3x1 caps pc
08/09/2020
• S : Nyeri perut atas (+), Demam (-)
• O : TD : 125/79 N : 87x/m RR: 20x/m
S: 36,7
• Abdomen NTE (+)
• A: Trombositopenia ec ITP dd
Leukemia+ ISK + BSK
• P Dx: SGOT, SGPT, Malaria, Evaluasi
Hapusan darah tepi
• P Tx:
• Diet Lunak 1800 kkal
• IVFD RL 30tpm
• Inj Omz 2x40mg iv
• Inj ondancentron 3x4mg iv (prn
mual)
• Inj Ceftriaxone 2x1 gr iv
• Inj Metylprednisolon 1x62,5 mg
• Batugin Syr 3xCI pc
• Imunas Caps 3x1 caps pc
09/09/2020
• S : Nyeri perut atas (+), Demam (-)
• O : TD : 125/79 N : 87x/m RR: 20x/m
S: 36,7
• Abdomen NTE (+)
• A: Trombositopenia ec ITP dd
Leukemia+ ISK + BSK
• P Dx: SGOT, SGPT, Malaria, Evaluasi
Hapusan darah tepi
• P Tx:
• Diet Lunak 1800 kkal
• IVFD RL 30tpm
• Inj Omz 2x40mg iv
• Inj ondancentron 3x4mg iv (prn
mual)
• Inj Ceftriaxone 2x1 gr iv
• Inj Metylprednisolon 1x62,5 mg
• Paracetamol3x500mg po pc
• Batugin Syr 3xCI pc
• Imunas Caps 3x1 caps pc
 08-09-2020
07-09-2020 • SGOT : 29 U/L
• HB: 11,4 G/DL
• HB: 13,4 G/DL
• HT: 34,6 % • SGPT : 20 U/L • HT: 40,8 %
• WBC :14,8 10³/UL
• HBSAG : NEGATIVE • WBC :12,5 10³/UL
• PLATELETS : 3 10³/UL
• DIFF COUNT:
• MALARIA : (-) • PLATELETS : 4 10³/UL
• LIMPHOCYTES : 5,8 % L
• DIFF COUNT:
• MID : 8,7 % L
• GRANULOCYTE : 85,5 H
• LIMPHOCYTES : 9,9 % L
• NS : - • MID : 8,9 % L
• IGG DENGUE : (-) • GRANULOCYTE : 81,2H
• IGM DENGUE : (-)
 09/09/2020
• PERIPHERAL BLOOD EVALUATION
• erythrosite : Normositik Normocrome
• leukocytes : Count >>, Normal morphology, Diff Manual : B/E/BF/Seg/Limf/Mono : 0/0/2/39/7/2
• Tromb : Count <<, Giant Platelet (+)
• conclusion :Anemia Normositik normocrom, limfositopenia limfositopenia, Trombositopenia
10-09-2020 11-09-2020 12-09-2020
S: Demam (-), Perdarahan Gusi (-), Bintik S: FEVER(-), BLEEDING (-) S:-
Merah Di Kulit (-)
O: BP : 125/75MMHG, HR: 80X/M, T: 36,5 , O: BP : 125/75MMHG,HR: 80X/M, T: 36,5 ,
O: TD : 125/75mmhg, N: 80x/M, S: 36,5 , RR: 20 RR: 20
RR: 20
ABD : TENDERNESS PAIN IN ABD : TENDERNESS PAIN IN
ABD : TENDERNESS PAIN IN EPIGASTRIC REGIO (-) EPIGASTRIC REGIO (-)
EPIGASTRIC REGIO (-)
A: ITP + UTI + UTS A: ITP + UTI + UTS
A: ITP + UTI + UTS
P P
P
DIET HCHP 2100ICCAL/DAY
DIET HCHP 2100ICCAL/DAY
IVFD RL 1000 CC/24 H - 10 GTT TREATMNT IN HOME
IVFD RL 1000 CC/24 H - 10 GTT
IV: OMEPRAZOLE 1X40 MG IV CEFADROXYL 2X500MG PC
IV: Omeprazole 1x40 Mg Iv
METYLPREDNISOLONE 2X62,5 MG OMEPRAZOLE 2X1 CAP AC
Ceftriaxone 2x1gr Iv PO: METYLPREDNISOLONE 3X62,5 MG PC
Metylprednisolone 2x62,5 Mg • BATUGYN SYR 3XCI PC BATUGYN SYR 3XCI PC
Po: • DL/24 JAM , UL ULANG
 10/09/2020 11/09/2020

• HB: 11,1 G/DL URINE TEST

• HB: 11 G/DL LEUKOCYTES : -
• HT: 34,7 %
• HT: 34,3 % PROTEIN -
• WBC :8,2 10³/UL PH 5
• WBC :10,1 10³/UL
• PLATELETS : 15 10³/UL BLOOD : -
• PLATELETS : 20 10³/UL SEDIMEN:
• DIFF COUNT:
• DIFF COUNT: ERITHROCYTE : 0-1/LPB
• LIMPHOCYTES : 13,6 % L
• MID : 11,9 % L • LIMPHOCYTES : 6,8 % L SQUAMOSE EPITEL CELLS : +
LEUKOCYTES : 1-3
• GRANULOCYTE : 74,5 H • MID : 7,2 % L
URIC ACID CRISTAL : +
• GRANULOCYTE : 86 H
BACTERIA :+2
 CASE
DISCUSSION
TEORI CASE
• WOMEN, 31 YO
• REPRRODUCTIVE AGE
TEORI CASE
• FEVER.
• MENSTRUATION WAS 3 YEARS AGO
AFTER GET CONTRACEPTION

• RUMPLE LEED (+)

• TENDERNESS PAIN IN EPIGASTRIC
REGIO
TEORI CASE
• PB: Giant Platelet (+)
conclusion :Anemia Normositik
normocrom, limfositopenia
limfositopenia, Trombositopenia
• HEMATOLOGY TEST : PLATELET <<<,
HT ==
THEORY CASE
• CORTICOSTEROIDS :
METYLPREDNISOLONE 2X62,5 MG SP
• HT : PLATELET COUNT >>
 CONCLUTION

1. INITIALLY KNOWN AS “IDIOPATHIC THROMBOCYTOPENIC PURPURA, IMMUNE THROMBOCYTOPENIA (ITP)

IS AN ACQUIRED HEMORRHAGIC CONDITION CHARACTERIZED BY THE ACCELERATED CLEARANCE OF
PLATELETS CAUSED BY ANTIPLATELET AUTOANTIBODIES SUCH AS ANTI-GLYCOPROTEIN (GP) IIB/IIIA
2. BLEEDING IS THE MOST COMMON CLINICAL MANIFESTATION OF ITP, PRESENTING AS MUCOCUTANEOUS
BLEEDING INVOLVING THE SKIN, ORAL CAVITY AND GASTROINTESTINAL TRACT. PURPURA, USUALLY ON
THE EXTREMITIES (“DRY PURPURA”) MAY OFTEN APPEAR WITHOUT AN OBVIOUS PRECIPITATING EVENT.
MUCOSAL BLEEDING INCLUDE EPISTAXIS, MENORRHAGIA, AND GINGIVAL AND GASTROINTESTINAL
BLEEDING. BUT IN SEVERAL PATIENT MAY BE ASYMPTOMS.
3. ITP IS SELF LIMITING DISEASE. ITP HAS DIVIDED THERAPIES INTO FIRST LINE TREATMENTS—
CONSISTING OF CORTICOSTEROIDS, IVIG AND IV ANTI-D, AND SECOND LINE THERAPIES WHICH CONSIST OF
SPLENECTOMY AND ALL OTHER MEDICAL APPROACHES
THANK YOU