What are the complications of idiopathic thrombocytopenic purpura (ITP)?

Complications of Idiopathic Thrombocytopenia

The most serious complication of idiopathic thrombocytopenic purpura (ITP) is intracranial hemorrhage, which accounts for the majority of fatal bleeding events with an estimated mortality rate of 5% in adults. 1

Hemorrhagic Complications

• Bleeding is the primary complication of ITP, with severity generally correlating with the degree of thrombocytopenia 1
• Intracranial hemorrhage is the most dangerous complication and main cause of death in ITP patients 1
• Risk of fatal hemorrhage is higher in adults (estimated 5%) compared to children (0.5-0.9%) 1
• Most severe bleeding occurs when platelet counts fall below 10,000/μL 2
• Bleeding manifestations range from minor to severe:
  • Minor: Petechiae, purpura, bruising 1
  • Moderate: Epistaxis, gingival bleeding, menorrhagia 1
  • Severe: Gastrointestinal hemorrhage, extensive mucosal bleeding 1
  • Life-threatening: Intracranial hemorrhage 1

Risk Factors for Bleeding Complications

• Platelet count <20,000/μL significantly increases bleeding risk 2
• Advanced age (>60 years) may be associated with higher risk of hemorrhagic complications at equivalent platelet counts 1
• Previous history of bleeding increases risk of future bleeding events 2
• Comorbid conditions that increase bleeding risk:
  • Gastrointestinal disease
  • Central nervous system disease
  • Urologic disease 1
• Medications that exacerbate bleeding risk (e.g., aspirin, anticoagulants) 1
• Lifestyle factors involving trauma risk or vigorous activity 1

Pregnancy-Related Complications

• Maternal risks include increased bleeding during delivery 1
• Fetal/neonatal risks:
  • Approximately 10% of infants born to mothers with ITP have platelet counts <50,000/μL 1
  • About 4% have platelet counts <20,000/μL 1
  • Risk of neonatal intracranial hemorrhage exists but is relatively low 1

Treatment-Related Complications

• Corticosteroid therapy:
  • Long-term use associated with significant adverse effects including weight gain, hypertension, diabetes, osteoporosis, and increased infection risk 1
• Splenectomy:
  • Operative and postoperative complications including bleeding and infection 1
  • Long-term risk of fatal bacterial infection, particularly in children <5 years old (estimated 1 death per 300-1,000 patient-years) 1
• Thrombopoietin receptor agonists:
  • Eltrombopag: Risk of hepatotoxicity, thrombotic/thromboembolic complications (particularly portal vein thrombosis), and cataracts 3
  • Romiplostim: Potential for thrombotic/thromboembolic complications, bone marrow reticulin formation and collagen fibrosis 4
• Rituximab and immunosuppressants:
  • Increased risk of infections due to immunosuppression 5

Chronic Disease Complications

• Persistent thrombocytopenia despite treatment occurs in approximately 5-10% of adult patients 1
• Psychological impact:
  • Anxiety and reduced quality of life due to chronic disease burden 1
  • Limitations on activities and lifestyle 1
• Need for ongoing monitoring and treatment 6

Special Considerations in Children vs Adults

• ITP in children:
  • Generally more benign course with 70-80% achieving spontaneous remission within 6 months 1
  • Lower risk of fatal hemorrhage (0.5-0.9%) compared to adults 1
• ITP in adults:
  • Typically chronic disease course with less frequent spontaneous remissions 1
  • Higher risk of fatal hemorrhage (approximately 5%) 1
  • More likely to require long-term treatment 6

Monitoring Recommendations

• Regular assessment of bleeding symptoms and platelet counts 1
• Baseline ocular examination and monitoring for cataracts, especially with eltrombopag treatment 3
• Monitoring for signs of infection, particularly in splenectomized patients 1
• Liver function tests for patients on thrombopoietin receptor agonists 3
• Bone marrow examination in selected patients with atypical features or treatment failure 1