From the Guidelines
Elevated patient petechiae is most likely a sign of thrombocytopenia, which requires immediate medical attention to rule out immune thrombocytopenia (ITP) or other bleeding disorders, as it can lead to severe bleeding and increased mortality, as reported in the 2019 American Society of Hematology guidelines for ITP 1.
Clinical Presentation
Petechiae in an elevated patient position can be a sign of an underlying condition such as ITP, which is characterized by a low platelet count resulting from platelet destruction and impaired platelet production, as described in the 2019 American Society of Hematology guidelines for ITP 1. The clinical presentation of ITP can vary, with some patients experiencing mild symptoms such as bruising and petechiae, while others may have more severe bleeding events, including mucosal bleeding and intra-cranial hemorrhage (ICH).
Management
The management of ITP involves addressing the underlying cause of the condition, which may include treatment of the underlying autoimmune disorder or infection, as well as management of bleeding symptoms, as recommended in the 2019 American Society of Hematology guidelines for ITP 1. Patients with ITP should be advised to change positions slowly to minimize sudden pressure changes in blood vessels, and supportive measures such as avoiding prolonged standing, elevating legs when sitting, and wearing compression stockings may be recommended.
Diagnostic Evaluation
A complete blood count and coagulation studies should be performed to rule out thrombocytopenia or other bleeding disorders, as recommended in the 2019 American Society of Hematology guidelines for ITP 1. If petechiae are accompanied by other symptoms such as easy bruising, bleeding gums, or blood in urine or stool, immediate medical attention is necessary to rule out a more serious underlying condition.
Key Considerations
- ITP has a significant impact on health-related quality of life (HRQoL), particularly in the first year after diagnosis, related to restrictions on activities, anxiety due to the risk of bleeding, and the burden of treatment and monitoring, as reported in the 2019 American Society of Hematology guidelines for ITP 1.
- Adults with ITP have a 1.3- to 2.2-fold higher mortality than the general population due to cardiovascular disease, infection, and bleeding, as reported in the 2019 American Society of Hematology guidelines for ITP 1.
- The decision to treat ITP is highly complex and varies based on comorbidities, medications, and age, which all impact the risk of bleeding, as recommended in the 2019 American Society of Hematology guidelines for ITP 1.
From the Research
Elevated PT Petechiae
- Petechiae are small spots on the skin that occur due to bleeding from small blood vessels, and an elevated PT (prothrombin time) indicates a coagulopathy, which can be caused by various factors including liver disease 2, 3.
- In patients with liver disease, coagulopathy can result from impairments in the clotting and fibrinolytic systems, as well as from reduced number and function of platelets 2.
- Treatment of coagulopathy in liver disease includes vitamin K replacement, transfusion of fresh frozen plasma, and platelet transfusions 2, 3.
- However, prophylactic fresh frozen plasma and platelet transfusions may have a prothrombotic effect in patients with liver disease, and their use should be carefully considered 4.
- Four-factor prothrombin complex concentrate (4F-PCC) has been used to reverse coagulopathy in patients with liver disease, but its efficacy is suboptimal and further studies are needed to optimize its use 5.
- Vitamin K replacement is also used to treat warfarin-associated coagulopathy, and daily vitamin K supplementation can help regulate international normalized ratios in difficult-to-control patients 6.
Coagulopathy Treatment
- The goal of therapy is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis 3.
- Treatment options include:
- Vitamin K replacement
- Transfusion of fresh frozen plasma
- Platelet transfusions
- Cryoprecipitate therapy
- Plasma exchange
- Prothrombin complex concentrates
- Recombinant activated factor VIIa
- Thrombopoietin therapy
- The choice of treatment depends on the underlying cause of the coagulopathy, the severity of the coagulopathy, and the presence of bleeding or other complications 2, 3.
Liver Disease and Coagulopathy
- Liver disease can cause coagulopathy due to impairments in the clotting and fibrinolytic systems, as well as from reduced number and function of platelets 2.
- Coagulopathy in liver disease can be treated with vitamin K replacement, transfusion of fresh frozen plasma, and platelet transfusions 2, 3.
- However, liver transplantation is the ultimate intervention that corrects coagulopathy of advanced liver disease and liver failure 3.