This condition is now more commonly referred to as immune thrombocytopenia ITP. ITP can cause excessive bruising and bleeding. An unusually low level of platelets, or thrombocytes, in the blood results in ITP. Platelets are produced in the bone marrow.
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Idiopathic thrombocytopenic purpura ITP is defined as a hematologic disorder, characterized by isolated thrombocytopenia without a clinically apparent cause. The major causes of accelerated platelet consumption include immune thrombocytopenia, decreased bone marrow production, and increased splenic sequestration. The clinical presentation may be acute with severe bleeding, or insidious with slow development with mild or no symptoms.
Treatment should be restricted to those patients with moderate or severe thrombocytopenia who are bleeding or at risk of bleeding. We present a case report on ITP with clinical presentation, diagnosis and management. Idiopathic thrombocytopenic purpura ITP is the condition of having a low platelet count thrombocytopenia of no known cause idiopathic.
As most causes appear to be related to antibodies against platelets, it is also known as immune thrombocytopenic purpura.
Although most cases are asymptomatic, very low platelet counts can lead to a bleeding diathesis and purpura. ITP is a disorder that affects the overall number of blood platelets rather than their function. ITP may be either acute or chronic. The incidence of ITP is new cases per million per year, with children accounting for half of that amount and the median age of adults at the diagnosis is Recent evidence suggests that the stimulus for autoantibody production in ITP is due to abnormal T helper cells reacting with platelet antigens on the surface of antigen presenting cells.
The diagnosis of ITP is a diagnosis of exclusion. First, one has to make sure that there are no other blood abnormalities except for low platelet count and no physical signs except for signs of bleeding. Secondary causes could be leukemia, medications e. The size and appearance of the platelets may be abnormal.
Bleeding time is usually prolonged. Bleeding time is prolonged in ITP patients; however, the use of bleeding time in diagnosis is discouraged by the American Society of Hematology practice guidelines as useless.
On examination of the bone marrow, an increase in the production of megakaryotes is seen and can help in determining ITP. It should be limited in duration unless demonstrated that symptomatic thrombocytopenia persists. Patients with mild, asymptomatic thrombocytopenia, discovered incidentally on a routine blood count, should not be treated. History of presenting illness revealed that patient noticed bleeding from his gums in lower front teeth region approximately 2 weeks before reporting to department and patient was having purpuric spots on body legs, hands, and neck since past 2 months.
Past medical history revealed that patient was known case of epilepsy since 7 years of age and was on tablet eptoin, tablet carbamazepine for past 12 years. Patient was also the known case of ischemic heart disease for past 7 years. Patient started treatment 7 years back and was on tablet isosorbide dinitrate 10 mg, tablet atenelol 25 mg, tablet envas 5 mg and patient had discontinued aspirin 6 months back.
Extraoral examination revealed petechial spots over the neck on right side [ Figure 1 ], petechial spots over the forearms, and petechial spots over the right arm [ Figure 2 ].
Intraoral examination revealed bleeding from gingiva in lower anterior region, which was inflamed, reddish, tender on palpation, soft in consistency [ Figure 3 ]. Petechial spots on dorsum of tongue, petechial spot on left side hard palate and left maxillary tuberosity region. On the 2 nd day after the patient reported, there was increased bleeding, hematoma and gingival enlargement in lower anterior region [ Figure 4 ], and on the 4 th day, hematoma formation was seen in lower anterior region lingually [ Figure 5 ].
Based on the clinical findings, provisional diagnosis was made as ITP. Pertinent investigations were advised to the patient. Other biochemical examinations, liver function tests, and ultrasonography of abdomen were normal. Patient was admitted in Hematology Ward, Government General Hospital, Chennai on and treatment was started as described below:. No complications were observed and all the lesions were resolved completely.
All the petechial lesions were completely resolved over the neck, arm, and forearms. Intraorally there was complete resolution of hematoma anteriorly on gingiva [ Figure 6 ], hematoma in lower anterior lingual region [ Figure 7 ], and petechiae over dorsum of tongue.
The patient was followed-up for 2 years and there was no re-occurence reported. There is marked variability in the clinical presentation of ITP. Our case was abrupt and acute in onset. The bleeding manifestations of thrombocytopenia are described as mucocutaneous to distinguish them from coagulation disorders like hemophilia.
Petechia, purpura, and easy bruising are expected in ITP. Less common are epistaxis, gingival bleeding, and menorrhagia.
Uncommon findings are gastrointestinal GI bleeding, gross hematuria and intracranial hemorrhage. Older patients have more severe and rare bleeding manifestations, such as GI bleeding and possibly intracranial hemorrhage secondary to co-morbidities such as hypertension. The diagnosis of ITP is in part one of exclusion, requiring that other causes of thrombocytopenia be ruled out. The major goal for treatment of ITP is to provide a safe platelet count to prevent major bleeding and avoid unnecessary treatment of asymptomatic patients with mild to moderate thrombocytopenia.
Spontaneous remissions are unusual in adults. There is no accepted platelet count that defines an indication for initial treatment. The decision to treat ITP is based on the platelet count, degree of bleeding, and patient's lifestyle.
There is no specific treatment for ITP. General care includes explaining ITP to the patient and advising him or her to watch for bruising, petechiae, or other signs of recurrence.
Children should be discouraged from rough contact sports or other activities that increase the risk of trauma. Patients are also advised to avoid using aspirin or ibuprofen as pain relievers because these drugs lengthen the clotting time of blood.
All medications for ITP are given either orally or IV; intramuscular injection is avoided due to the possibility of causing bleeding into the skin. Corticosteroids, typically prednisone, are the backbone of the initial treatment. The treatment begins with IV steroids methylprednisolone or prednisone , IVIg or their combination and sometimes platelet infusions in order to raise the count quickly.
Most cases respond during the 1 st week of treatment. After several weeks of prednisone therapy, the dose is gradually reduced. Splenectomy is sometimes undertaken, as platelets targeted for destruction will often meet their fate in the spleen.
Other immunosuppresants, which are steroid sparing drugs like mycophenolate mofetil and azathioprine, are becoming more popular for their effectiveness. Platelet transfusion is not normally recommended and is usually unsuccessful in raising a patient's platelet count.
This is because the underlying autoimmune mechanism that destroyed the patient's platelets to begin with will also destroy donor platelets. An exception to this rule is when a patient is bleeding profusely, when transfusion of platelets can quickly form a platelet plug to stop bleeding.
Dapsone also called diphenylsulfone, DDS, or avlosulfon is an anti-infective sulfone drug. In recent years, dapsone has also proved helpful in treating lupus, rheumatoid arthritis and as a second-line treatment for ITP.
The exact mechanism by which dapsone assists in ITP is unclear. It is a thrombopoiesis stimulating Fc-peptide fusion protein peptibody. Initial clinical trials show it to be effective in chronic ITP. For patient with active H. The initial treatment of ITP includes: 1 Treatment should be restricted to those patients with moderate or severe thrombocytopenia who are bleeding or at risk of bleeding; 2 treatment should be limited in duration unless it is demonstrated that symptomatic thrombocytopenia persists; and 3 patients with mild, asymptomatic thrombocytopenia, discovered incidentally on a routine blood count, should not be treated.
Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Contemp Clin Dent v. Contemp Clin Dent. Kayal , S. Jayachandran , and Khushboo Singh. Author information Copyright and License information Disclaimer. Correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.
This article has been cited by other articles in PMC. Abstract Idiopathic thrombocytopenic purpura ITP is defined as a hematologic disorder, characterized by isolated thrombocytopenia without a clinically apparent cause.
Keywords: Hematoma, idiopathic thrombocytopenic purpura, petechiae, platelets. Introduction Idiopathic thrombocytopenic purpura ITP is the condition of having a low platelet count thrombocytopenia of no known cause idiopathic. Open in a separate window. Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Discussion There is marked variability in the clinical presentation of ITP.
Conclusion The initial treatment of ITP includes: 1 Treatment should be restricted to those patients with moderate or severe thrombocytopenia who are bleeding or at risk of bleeding; 2 treatment should be limited in duration unless it is demonstrated that symptomatic thrombocytopenia persists; and 3 patients with mild, asymptomatic thrombocytopenia, discovered incidentally on a routine blood count, should not be treated.
References 1. Management of adult idiopathic thrombocytopenic purpura. Annu Rev Med. Cellular immune mechanisms in autoimmune thrombocytopenic purpura: An update.
Immune thrombocytopenic purpura
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Idiopathic Thrombocytopenic Purpura (ITP)
Immune thrombocytopenia ITP is a disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets — the cells that help blood clot. Formerly known as idiopathic thrombocytopenic purpura, ITP can cause purple bruises, as well as tiny reddish-purple dots that look like a rash. Children may develop ITP after a viral infection and usually recover fully without treatment. In adults, the disorder is often long term.
Idiopathic thrombocytopenic purpura
Immune thrombocytopenia purpura ITP , also known as idiopathic thrombocytopenic purpura , is a type of thrombocytopenic purpura defined as an isolated low platelet count with a normal bone marrow in the absence of other causes of low platelets. Two distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults. The acute form often follows an infection and spontaneously resolves within two months. Chronic immune thrombocytopenia persists longer than six months with a specific cause being unknown. ITP is an autoimmune disease with antibodies detectable against several platelet surface structures. ITP is diagnosed by identifying a low platelet count on a complete blood count a common blood test.