What are the signs and management of thrombocytopenia?

Signs and Management of Thrombocytopenia

Thrombocytopenia, defined as a platelet count less than 150 × 10³/μL, presents with characteristic bleeding manifestations that vary in severity depending on the platelet count and requires prompt recognition and appropriate management to prevent serious complications. 1

Clinical Manifestations of Thrombocytopenia

Bleeding Signs Based on Platelet Count

• Platelet count >50 × 10³/μL: Generally asymptomatic 1
• Platelet count 20-50 × 10³/μL: Mild skin manifestations
  • Petechiae (pinpoint red spots)
  • Purpura (larger red/purple patches)
  • Ecchymosis (bruising)
• Platelet count <20 × 10³/μL: More significant bleeding
  • Spontaneous gingival bleeding
  • Epistaxis (nosebleeds)
  • Menorrhagia (heavy menstrual bleeding)
• Platelet count <10 × 10³/μL: High risk of serious bleeding 1
  • Gastrointestinal hemorrhage
  • Extensive skin and mucosal hemorrhage
  • Intracranial hemorrhage (ICH) - occurs in approximately 0.5% of children and 1.5% of adults with ITP 2

Specific Oral and Mucosal Signs

• Blood-filled vesicles and blisters on lips, tongue, and buccal mucosa
• Hemorrhagic petechiae on the palate
• Spontaneous gingival bleeding 3
• Hyposphagma (hemorrhagic extravasation in the ocular sclera) 3

Management of Thrombocytopenia

General Principles

1. Treatment decisions should be based on bleeding symptoms rather than platelet count alone 2
2. For chronic ITP, use the least toxic treatment at the lowest effective dose 2
3. Emergency treatment of severe bleeding requires combination therapy 2
4. Early aggressive therapy may result in durable platelet count responses 2

Activity Restrictions

• Patients with platelet counts <50 × 10³/μL should avoid activities with risk of trauma 1
• Children should not participate in competitive contact activities with high risk of head trauma 4
• Other activities generally need not be restricted; children should be encouraged to continue schooling 4

Management Based on Severity (ITP-specific)

For Mild/Moderate Symptoms (Platelet count >20 × 10³/μL)

• Outpatient management with supportive care 4
• Consider:
  • Antifibrinolytic agents
  • Oral contraceptives (for menorrhagia)
  • Weekly or less frequent outpatient visits 4

For Severe Symptoms or Platelet Count <10 × 10³/μL

• First-line treatment options:
  • IV immunoglobulin (IVIg): 0.8-1 g/kg single dose; effective in >80% of patients within 1-2 days 4
  • IV anti-D (for Rh-positive patients): 50-75 μg/kg; 50-77% response rate within 24 hours 4
  • Corticosteroids: Prednisone 1-2 mg/kg/day (maximum 14 days) or 4 mg/kg/day for 3-4 days; 75% response rate within 2-7 days 4

For Emergency/Life-Threatening Bleeding

• Combination therapy:
  • Platelet transfusion (2-3 times usual dose)
  • High-dose IV corticosteroids
  • IVIg or IV anti-D 4

Platelet Transfusion Guidelines

• Recommended for:
  • Active hemorrhage
  • Platelet counts <10 × 10³/μL
  • Before invasive procedures to ensure adequate platelet counts 1

Special Considerations for Cancer-Associated Thrombocytopenia

• Full-dose anticoagulation is safe when platelet count is >50 × 10³/μL 4
• For platelet counts <50 × 10³/μL with required anticoagulation:
  • Consider full-dose anticoagulation with transfusion support (maintaining platelets >40-50 × 10³/μL)
  • Alternative: dose-modified anticoagulation 4

Important Caveats and Pitfalls

1. Rule out pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count 1

2. Distinguish between acute and chronic thrombocytopenia by reviewing previous platelet counts 1

3. Recognize conditions requiring emergency hospitalization:

   • Heparin-induced thrombocytopenia
   • Thrombotic microangiopathies
   • HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) 1

4. Be aware that some thrombocytopenic conditions can paradoxically cause thrombosis:

   • Antiphospholipid syndrome
   • Heparin-induced thrombocytopenia
   • Thrombotic microangiopathies 1

5. "Spontaneous" bleeding in thrombocytopenia is often triggered by subclinical processes rather than being truly spontaneous 5

6. Consider TPO receptor agonists (e.g., eltrombopag) for persistent or chronic ITP in patients who have had insufficient response to corticosteroids, immunoglobulins, or splenectomy 6