Tuesday Conference Approach to Thrombocytopenia Selim Krim, MD Assistant Professor TTUHSC

Case 1 A 35-year-old woman is hospitalized for recurrent thrombophlebitis and a pulmonary embolus and is started on heparin.A 35-year-old woman is hospitalized for recurrent thrombophlebitis and a pulmonary embolus and is started on heparin. Two weeks earlier, she had completed a 6- month anticoagulation therapeutic regimen. A CBC on day 5 of her hospitalization shows a platelet count of 70,000/mm3.Two weeks earlier, she had completed a 6- month anticoagulation therapeutic regimen. A CBC on day 5 of her hospitalization shows a platelet count of 70,000/mm3.

MCQ 1 Which of the following is NOT associated with thrombocytopenia? Which of the following is NOT associated with thrombocytopenia? Thrombotic thrombocytopenia purpuraThrombotic thrombocytopenia purpura Immune thrombocytopenic purpuraImmune thrombocytopenic purpura Heparin induced thrombocytopeniaHeparin induced thrombocytopenia CirrhosisCirrhosis Polycythemia veraPolycythemia vera

MCQ 2 Which is NOT associated with TTP? Which is NOT associated with TTP? Megaloblastic anemiaMegaloblastic anemia FeverFever Central nervous system signsCentral nervous system signs ThrombocytopeniaThrombocytopenia Renal dysfunctionRenal dysfunction

MCQ 3 Which drug has NOT been implicated as a possible cause of TTP? Which drug has NOT been implicated as a possible cause of TTP? TiclopidineTiclopidine CyclosporineCyclosporine TacrolimusTacrolimus QuinineQuinine FluorouracilFluorouracil

MCQ 4 Which is INCORRECT about ITP? Which is INCORRECT about ITP? It is as common in children as it is in adultsIt is as common in children as it is in adults It occurs more in adults men than in adult womenIt occurs more in adults men than in adult women It can be secondary to other diseasesIt can be secondary to other diseases A bone marrow is not required for all patientsA bone marrow is not required for all patients Evans syndrome describes a combination of hemolytic anemia with ITPEvans syndrome describes a combination of hemolytic anemia with ITP

MCQ 5 Which treatment is NOT indicated for ITP? Which treatment is NOT indicated for ITP? Corticosteroids Corticosteroids Intravenous immunoglobulin Intravenous immunoglobulin Plasmapheresis Plasmapheresis Anti-D immune globulin Anti-D immune globulin Splenectomy Splenectomy

MCQ 6 Which of the following patient populations has the highest risk of HIT (assume all are receiving the same dose of heparin)? Which of the following patient populations has the highest risk of HIT (assume all are receiving the same dose of heparin)? After general surgeryAfter general surgery Hospitalized pediatric patientsHospitalized pediatric patients After orthopedic surgeryAfter orthopedic surgery Hospitalized general internal medicine patientsHospitalized general internal medicine patients Hospitalized obstetric patientsHospitalized obstetric patients

MCQ 7 Which is least suggestive of HIT? Which is least suggestive of HIT? Platelet count<20,000/ mm3 Platelet count<20,000/ mm3 Venous thrombosis Venous thrombosis Arterial thrombosis Arterial thrombosis Low molecular-weight heparin use within the previous week Low molecular-weight heparin use within the previous week Abnormal serotonin release assay Abnormal serotonin release assay

MCQ 8 How should one monitor for HIT in patients receiving heparin after undergoing orthopedic surgery? How should one monitor for HIT in patients receiving heparin after undergoing orthopedic surgery? Daily platelet countsDaily platelet counts Platelet counts every other day from day 4 to 14 of heparin treatmentPlatelet counts every other day from day 4 to 14 of heparin treatment Platelet counts at days 7 and 14 of heparin treatmentPlatelet counts at days 7 and 14 of heparin treatment Antibody levels for all patients at day 14 of therapyAntibody levels for all patients at day 14 of therapy Never unless thrombosis is suspectedNever unless thrombosis is suspected

MCQ 9 Which is NOT considered important in the initial treatment of HIT type II? Which is NOT considered important in the initial treatment of HIT type II? Discontinuation of all heparinDiscontinuation of all heparin Avoidance of warfarinAvoidance of warfarin Initiation of ArgatrobanInitiation of Argatroban Initiate aspirin therapyInitiate aspirin therapy

Key Points Consider TTP if the following pentad is met: fever, renal failure, thrombocytopenia, CNS involvement, and microangiopathic hemolytic anemia.Consider TTP if the following pentad is met: fever, renal failure, thrombocytopenia, CNS involvement, and microangiopathic hemolytic anemia. ITP is more common in females and equally affects children and adults.ITP is more common in females and equally affects children and adults. HIT is most often encountered in orthopedic patients taking heparin.HIT is most often encountered in orthopedic patients taking heparin.

Key Points HIT can cause a coagulopathy with venous or arterial thrombi.HIT can cause a coagulopathy with venous or arterial thrombi. If HIT occurs, all heparin products should be discontinued and a non-heparin, non- warfarin anticoagulant should be initiated.If HIT occurs, all heparin products should be discontinued and a non-heparin, non- warfarin anticoagulant should be initiated. In HIT alternative anticoagulation should continue for at least 2 weeks after heparin has been discontinued.In HIT alternative anticoagulation should continue for at least 2 weeks after heparin has been discontinued.

Thank You