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
 IDENTITY
• 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
SEPTEMBER 6TH 2020

FEVER
 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
Diagnose
• Fever D1ec Dengue FeverddDHF
• SuspUrinary track infection

(ER)
• IVFD Ringer Lactate 20tpm
• Inj:Ceftriaxone2 x1grIV(ST)

Treatment Injomeprazole2x40mgIV
•
• InjOndacentrone3x4mgIV
• Paracetamol3x500mgpo
• GG3x100mgpo
• R/Check Urine Test
 07/09/2020
• S: Upper abdominal pain (+),fever↑↓
• O :BP: 125/79HR: 87x/m RR:
20x/mT:36,9
• Stomach: epigastria tenderness
(+),Suprapubictenderness +
• A:Susp ITP + UTI + UT Stone
• PTx:
• Soft diet 1800 kcal
• IVFD RL30gtt
• InjOmz2x40mgiv
• Injondancentron3x4mgiv
• InjAsamTranexamat3x500mgiv
• InjCeftriaxone2x1griv
• Paracetamol3x500 mgpopc
• BatuginSyr3xCIpc
• ImunasCaps 3x1caps pc
08/09/2020
• S : Upper abdominal pain (+),fever↑↓
• O :BP: 125/79HR: 87x/m RR:
20x/mT:36,7
• Stomach: epigastria tenderness (+)
• A:Trombositopenia ITPddLeukemia +
UTI + UT Stone
• PDx: SGOT, SGPT,Malaria, Blood
smear
• PTx:
• Soft diet 1800 kcal
• IVFD RL30gtt
• InjOmz2x40mgiv
• Injondancentron3x4mgiv(if Nausea)
• InjCeftriaxone2x1gr iv
• InjMetylprednisolon1x62,5mg
• BatuginSyr3xCIpc
• ImunasCaps3x1 caps pc
09/09/2020
• S: Upper abdominal pain (+), fever(-)
• O :BP: 125/79HR: 87x/m RR:
20x/mT:36,7
• Stomach: epigastria tenderness (+)
• A:Trombositopeniaec
ITPddLeukemia+UTI + UT Stone
• PDx: SGOT, SGPT,Malaria, Blood
smear
• PTx:
• Soft diet 1800kkal
• IVFD RL30gtt
• InjOmz2x40 mgiv
• Injondancentron3x4 mgiv(if nausea)
• InjCeftriaxone2x1gr iv
• InjMetylprednisolon1x62,5mg
• Paracetamol3x500 mgpopc
• BatuginSyr3xCIpc
• ImunasCaps3x1 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: fever (-), bleeding (-) S: FEVER(-), BLEEDING (-)
S:-
O: BP : 117/70mmhg, HR: 82/M, T: 36,6 O: BP : 115/67MMHG, HR: 75X/M, T: 36,5 ,
O: BP : 125/75MMHG,HR: 80X/M, T: 36,5 ,
RR: 20 RR: 20
RR: 20
ABD : TENDERNESS PAIN IN ABD : TENDERNESS PAIN IN
EPIGASTRIC REGIO (-)
ABD : TENDERNESS PAIN IN
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 IVFD RL 1000 CC/24 H - 10 GTT

TREATMNT IN HOME
IV: Omeprazole 1x40 Mg Iv IV: OMEPRAZOLE 1X40 MG IV
CEFADROXYL 2X500MG PC
Ceftriaxone 2x1gr Iv
METYLPREDNISOLONE 2X62,5 MG
OMEPRAZOLE 2X1 CAP AC
PO:
Metylprednisolone 2x62,5 Mg
METYLPREDNISOLONE 3X16 MG PC
• BATUGYN SYR 3XCI PC
Po: BATUGYN SYR 3XCI PC
• DL/24 JAM , UL ULANG
• Batugyn Syr 3xci Pc

• Paracetamole 3x500mg Pc

• HT again
 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