Immune Thrombocytopenic Purpura Workup

  • Author: Craig M Kessler, MD; Chief Editor: Emmanuel C Besa, MD   more...
 
Updated: Jan 3, 2012
 

Laboratory Studies

  • Determination of complete blood cell (CBC) count
    • The hallmark of immune thrombocytopenic purpura (ITP) is isolated thrombocytopenia.
    • Anemia and/or neutropenia may indicate other diseases.
  • Peripheral blood smear
    • The morphology of red blood cells (RBCs) and leukocytes is normal.
    • The morphology of platelets is typically normal, with varying numbers of large platelets. Some persons with acute immune thrombocytopenic purpura (ITP) may have megathrombocytes or stress platelets, reflecting the early release of megakaryocytic fragments into the circulation.
    • If most of the platelets are large, approximating the diameter of RBCs, or if they lack granules or have an abnormal color, consider an inherited platelet disorder.
    • Clumps of platelets on a peripheral smear prepared from ethylenediaminetetraacetic acid (EDTA)–anticoagulated blood are evidence of pseudothrombocytopenia.[19] The diagnosis of this type of pseudothrombocytopenia is established if the platelet count is normal when repeated on a sample from heparin-anticoagulated or citrate-anticoagulated blood.
  • Test for antibodies to HIV
    • In patients who have risk factors for HIV infection, a blood sample should be tested with an enzyme immunoassay for anti-HIV.[20]
    • During the acute HIV retroviral syndrome, the results of the anti-HIV assay may be negative. In this situation, a polymerase chain reaction for HIV DNA is more reliable than the anti-HIV assay.
  • Test for antiplatelet antibodies
    • Assays for platelet antigen–specific antibodies, platelet-associated immunoglobulin, or other antiplatelet antibodies are available in some medical centers and certain mail-in reference laboratories.
    • The reliability of the results of a platelet antibody test is highly specific to the laboratory used. A negative antiplatelet antibody assay result does not exclude the diagnosis of immune thrombocytopenic purpura (ITP).[21] The authors do not recommend this test as part of the routine evaluation.
    • Testing for antiplatelet antibodies is not required to diagnose immune thrombocytopenic purpura (ITP).
  • Test for antinuclear antibodies
    • In selected women, the medical history may suggest a chronic, recurrent, multisystemic illness with vague, generalized signs or symptoms, such as recurrent, multiple, painful, tender, or swollen joints.
    • In such cases, a negative antinuclear antibody (ANA) result is useful in diagnosing immune thrombocytopenic purpura (ITP) if the patient's thrombocytopenia becomes chronic and resistant to treatment.
  • Direct antiglobulin test: If anemia and thrombocytopenia are present, a positive direct antiglobulin (Coombs) test result may help establish a diagnosis of Evans syndrome.
  • Helicobacter pylori testing
    • Studies from Italy[22, 23] and Japan[24, 25] indicate that many persons with immune thrombocytopenic purpura (ITP) have H pylori gastric infections and that eradication of H pylori results in increased platelet counts.
    • In the United States and Spain, the prevalence of H pylori infections does not appear to be increased in persons with immune thrombocytopenic purpura (ITP), and eradication of H pylori has not increased platelet counts.[26, 27]
    • Therefore, routine testing for H pylori infections in adults and children with ITP is not recommended.
Next

Imaging Studies

  • Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are relatively benign and useful noninvasive imaging studies that can be used to rule out other causes of thrombocytopenia. However, they are not part of the routine evaluation of patients who may have immune thrombocytopenic purpura (ITP).
  • Promptly perform CT scanning or MRI when the medical history or physical findings suggest serious internal bleeding.
Previous
Next

Procedures

  • The primary diagnostic evaluation is bone marrow aspiration and biopsy. Patients with immune thrombocytopenic purpura (ITP) have a normal-to-increased number of megakaryocytes in the absence of other significant abnormalities. The value of bone marrow evaluation for a diagnosis of immune thrombocytopenic purpura (ITP) is unresolved, and more data are needed to establish clear guidelines.[28]
  • In adults who are thrombocytopenic and older than 60 years, we examine the bone marrow to exclude myelodysplastic syndrome or leukemia.
  • In adults whose treatment includes corticosteroids, baseline pretreatment bone marrow aspiration may be useful for future reference. Many adults have treatment-resistant chronic immune thrombocytopenic purpura (ITP) evident after 3-6 months of treatment, and an alternative diagnosis may be pursued vigorously at that time. Marrow aspirate obtained before any steroid-induced changes may have occurred can be useful.
  • Perform bone marrow aspiration and biopsy to evaluate for possible hypoplasia or fibrosis before splenectomy is performed.
  • In children, bone marrow examination is not required for the diagnosis of acute immune thrombocytopenic purpura (ITP), except in those with atypical hematologic findings, such as immature cells on the peripheral smear or persistent neutropenia.[29] Many children with acute immune thrombocytopenic purpura (ITP) have an increased number of normal or atypical lymphocytes on the peripheral smear, reflecting a recent viral illness. Unresponsiveness to standard treatment after 6 months is an indication for bone marrow aspiration.
Previous
Next

Histologic Findings

Bone marrow aspirate

The cellularity of the aspirate and the morphology of erythroid and myeloid precursors should be normal. The number of megakaryocytes may be increased. Because the peripheral destruction of platelets is increased, megakaryocytes may be large and immature, although in many cases the megakaryocyte morphology is normal. Older patients require a careful examination of megakaryocyte morphology to exclude an early myelodysplastic syndrome.

Bone marrow biopsy

Sections of a needle biopsy specimen or marrow clot should reveal normal marrow cellularity, without evidence of hypoplasia or increased fibrosis.

Splenic evaluation

The spleen reveals no specific findings. In adults, the microscopic finding of extramedullary hematopoiesis is atypical and indicates myeloid metaplasia. Carefully examine spleens removed from patients with immune thrombocytopenic purpura (ITP) for a primary splenic lymphoma or granuloma or other signs of an undiagnosed infectious disease.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Craig M Kessler, MD  Professor, Department of Medicine and Pathology, Division of Hematology/Oncology, Georgetown University School of Medicine; Director, Clinical Coagulation Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Hospital

Disclosure: NovoNordisk Honoraria Consulting; NovoNordisk Grant/research funds Other; Baxter-Immuno Honoraria Consulting

Coauthor(s)

S Gerald Sandler, MD, FACP, FCAP  Professor of Medicine and Pathology, Director, Transfusion Medicine, Department of Laboratory Medicine, Georgetown University Hospital

S Gerald Sandler, MD, FACP, FCAP is a member of the following medical societies: American Association of Blood Banks, College of American Pathologists, and International Society of Blood Transfusions

Disclosure: Nothing to disclose.

Rumina Bhanji, MD  Staff Physician, Departments of Pathology and Laboratory Medicine, Georgetown University Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Paul Kosty, MD  Associate Director, Associate Professor, Department of Internal Medicine, Divisions of Supportive Care Services and Hematology and Oncology, Ida M and Cecil H Green Cancer Center, Scripps Clinic

Michael Paul Kosty, MD is a member of the following medical societies: American College of Physicians, American Society of Hematology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald A Sacher, MB, BCh, MD, FRCPC  Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, and Royal College of Physicians and Surgeons of Canada

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD  Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Clinical Oncology, American Society of Hematology, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author S Gerald Sandler, MD, FACP, FCAP, to the development and writing of this article.

References

  1. Stasi R, Evangelista ML, Stipa E, et al. Idiopathic thrombocytopenic purpura: current concepts in pathophysiology and management. Thromb Haemost. Jan 2008;99(1):4-13. [Medline]. [Full Text].

  2. McMillan R. The pathogenesis of chronic immune thrombocytopenic purpura. Semin Hematol. Oct 2007;44(4 suppl 5):S3-S11. [Medline].

  3. Chan H, Moore JC, Finch CN, Warkentin TE, Kelton JG. The IgG subclasses of platelet-associated autoantibodies directed against platelet glycoproteins IIb/IIIa in patients with idiopathic thrombocytopenic purpura. Br J Haematol. Sep 2003;122(5):818-24. [Medline].

  4. Crow AR, Lazarus AH. Role of Fcgamma receptors in the pathogenesis and treatment of idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol. Dec 2003;25 suppl 1:S14-8. [Medline].

  5. Sandler SG. The spleen and splenectomy in immune (idiopathic) thrombocytopenic purpura. Semin Hematol. Jan 2000;37(1 suppl 1):10-2. [Medline].

  6. Fogarty PF, Segal JB. The epidemiology of immune thrombocytopenic purpura. Curr Opin Hematol. Sep 2007;14(5):515-9. [Medline].

  7. Segal JB, Powe NR. Prevalence of immune thrombocytopenia: analyses of administrative data. J Thromb Haemost. Nov 2006;4(11):2377-83. [Medline]. [Full Text].

  8. Danese MD, Lindquist K, Gleeson M, Deuson R, Mikhael J. Cost and mortality associated with hospitalizations in patients with immune thrombocytopenic purpura. Am J Hematol. Jul 16 2009;[Medline].

  9. Butros LJ, Bussel JB. Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis. J Pediatr Hematol Oncol. Aug 2003;25(8):660-4. [Medline].

  10. Medeiros D, Buchanan GR. Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome. J Pediatr. Sep 1998;133(3):334-9. [Medline].

  11. KUhne T, Imbach P, Bolton-Maggs PH, et al, for the Intercontinental Childhood ITP Study Group. Newly diagnosed idiopathic thrombocytopenic purpura in childhood: an observational study. Lancet. Dec 22-29 2001;358(9299):2122-5. [Medline].

  12. Michel M, Rauzy OB, Thoraval FR, et al. Characteristics and outcome of immune thrombocytopenia in elderly: results from a single center case-controlled study. Am J Hematol. Dec 2011;86(12):980-4. [Medline].

  13. Liebman H. Other immune thrombocytopenias. Semin Hematol. Oct 2007;44(4 suppl 5):S24-34. [Medline].

  14. Zheng T, Chunlei L, Zhen W, Ping L, Haitao Z, Weixin H, et al. Clinical-Pathological Features and Prognosis of Thrombotic Thrombocytopenic Purpura in Patients With Lupus Nephritis. Am J Med Sci. Sep 9 2009;[Medline].

  15. Rajantie J, Zeller B, Treutiger I, Rosthöj S. Vaccination associated thrombocytopenic purpura in children. Vaccine. Feb 26 2007;25(10):1838-40. [Medline].

  16. Black C, Kaye JA, Jick H. MMR vaccine and idiopathic thrombocytopaenic purpura. Br J Clin Pharmacol. Jan 2003;55(1):107-11. [Medline]. [Full Text].

  17. Visentin GP, Liu CY. Drug-induced thrombocytopenia. Hematol Oncol Clin North Am. Aug 2007;21(4):685-96, vi. [Medline]. [Full Text].

  18. Reese JA, Li X, Hauben M, Aster RH, Bougie DW, Curtis BR. Identifying drugs that cause acute thrombocytopenia: an analysis using 3 distinct methods. Blood. Sep 23 2010;116(12):2127-33. [Medline].

  19. Nilsson T, Norberg B. Thrombocytopenia and pseudothrombocytopenia: a clinical and laboratory problem. Scand J Haematol. Oct 1986;37(4):341-6. [Medline].

  20. Sundell IB, Koka PS. Thrombocytopenia in HIV infection: impairment of platelet formation and loss correlates with increased c-Mpl and ligand thrombopoietin expression. Curr HIV Res. Jan 2006;4(1):107-16. [Medline].

  21. Raife TJ, Olson JD, Lentz SR. Platelet antibody testing in idiopathic thrombocytopenic purpura. Blood. Feb 1 1997;89(3):1112-4. [Medline]. [Full Text].

  22. Emilia G, Luppi M, Zucchini P, et al. Helicobacter pylori infection and chronic immune thrombocytopenic purpura: long-term results of bacterium eradication and association with bacterium virulence profiles. Blood. Dec 1 2007;110(12):3833-41. [Medline]. [Full Text].

  23. Franchini M, Cruciani M, Mengoli C, Pizzolo G, Veneri D. Effect of Helicobacter pylori eradication on platelet count in idiopathic thrombocytopenic purpura: a systematic review and meta-analysis. J Antimicrob Chemother. Aug 2007;60(2):237-46. [Medline]. [Full Text].

  24. Inaba T, Mizuno M, Take S, et al. Eradication of Helicobacter pylori increases platelet count in patients with idiopathic thrombocytopenic purpura in Japan. Eur J Clin Invest. Mar 2005;35(3):214-9. [Medline].

  25. Sato R, Murakami K, Watanabe K, et al. Effect of Helicobacter pylori eradication on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura. Arch Intern Med. Sep 27 2004;164(17):1904-7. [Medline]. [Full Text].

  26. Ahn ER, Tiede MP, Jy W, et al. Platelet activation in Helicobacter pylori-associated idiopathic thrombocytopenic purpura: eradication reduces platelet activation but seldom improves platelet counts. Acta Haematol. 2006;116(1):19-24. [Medline].

  27. Michel M, Cooper N, Jean C, Frissora C, Bussel JB. Does Helicobacter pylori initiate or perpetuate immune thrombocytopenic purpura?. Blood. Feb 1 2004;103(3):890-6. [Medline]. [Full Text].

  28. Jubelirer SJ, Harpold R. The role of the bone marrow examination in the diagnosis of immune thrombocytopenic purpura: case series and literature review. Clin Appl Thromb Hemost. Jan 2002;8(1):73-6. [Medline].

  29. Calpin C, Dick P, Poon A, Feldman W. Is bone marrow aspiration needed in acute childhood idiopathic thrombocytopenic purpura to rule out leukemia?. Arch Pediatr Adolesc Med. Apr 1998;152(4):345-7. [Medline]. [Full Text].

  30. Sandler SG, Tutuncuoglu SO. Immune thrombocytopenic purpura - current management practices. Expert Opin Pharmacother. Dec 2004;5(12):2515-27. [Medline].

  31. Mazzucconi MG, Fazi P, Bernasconi S, et al. Therapy with high-dose dexamethasone (HD-DXM) in previously untreated patients affected by idiopathic thrombocytopenic purpura: a GIMEMA experience. Blood. Feb 15 2007;109(4):1401-7. [Medline]. [Full Text].

  32. Borst F, Keuning JJ, van Hulsteijn H, Sinnige H, Vreugdenhil G. High-dose dexamethasone as a first- and second-line treatment of idiopathic thrombocytopenic purpura in adults. Ann Hematol. Dec 2004;83(12):764-8. [Medline].

  33. Cheng Y, Wong RS, Soo YO, et al. Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. N Engl J Med. Aug 28 2003;349(9):831-6. [Medline]. [Full Text].

  34. Imbach P, Barandun S, d'Apuzzo V, et al. High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura in childhood. Lancet. Jun 6 1981;1(8232):1228-31. [Medline].

  35. Anderson D, Ali K, Blanchette V, et al. Guidelines on the use of intravenous immune globulin for hematologic conditions. Transfus Med Rev. Apr 2007;21(2 suppl 1):S9-56. [Medline].

  36. Sandler SG. Treating immune thrombocytopenic purpura and preventing Rh alloimmunization using intravenous rho (D) immune globulin. Transfus Med Rev. Jan 2001;15(1):67-76. [Medline].

  37. Sandler SG, Novak SC, Roland B. The cost of treating immune thrombocytopenic purpura using intravenous Rh immune globulin versus intravenous immune globulin. Am J Hematol. Mar 2000;63(3):156-8. [Medline]. [Full Text].

  38. Gaines AR. Acute onset hemoglobinemia and/or hemoglobinuria and sequelae following Rh(o)(D) immune globulin intravenous administration in immune thrombocytopenic purpura patients. Blood. Apr 15 2000;95(8):2523-9. [Medline]. [Full Text].

  39. Chun NS, Savani B, Seder RH, Taplin ME. Acute renal failure after intravenous anti-D immune globulin in an adult with immune thrombocytopenic purpura. Am J Hematol. Dec 2003;74(4):276-9. [Medline]. [Full Text].

  40. Tarantino MD, Buchanan GR. The pros and cons of drug therapy for immune thrombocytopenic purpura in children. Hematol Oncol Clin North Am. Dec 2004;18(6):1301-14, viii. [Medline].

  41. Dickerhoff R, von Ruecker A. The clinical course of immune thrombocytopenic purpura in children who did not receive intravenous immunoglobulins or sustained prednisone treatment. J Pediatr. Nov 2000;137(5):629-32. [Medline].

  42. Gernsheimer T, McCrae KR. Immune thrombocytopenic purpura in pregnancy. Curr Opin Hematol. Sep 2007;14(5):574-80. [Medline].

  43. Gottlieb P, Axelsson O, Bakos O, Rastad J. Splenectomy during pregnancy: an option in the treatment of autoimmune thrombocytopenic purpura. Br J Obstet Gynaecol. Apr 1999;106(4):373-5. [Medline].

  44. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. Mar 28 2002;346(13):995-1008. [Medline].

  45. Bussel JB. Novel approaches to refractory immune thrombocytopenic purpura. Blood Rev. Mar 2002;16(1):31-6. [Medline].

  46. McMillan R. Therapy for adults with refractory chronic immune thrombocytopenic purpura. Ann Intern Med. Feb 15 1997;126(4):307-14. [Medline].

  47. Godeau B, Durand JM, Roudot-Thoraval F, et al. Dapsone for chronic autoimmune thrombocytopenic purpura: a report of 66 cases. Br J Haematol. May 1997;97(2):336-9. [Medline].

  48. Facon T, Caulier MT, Wattel E, et al. A randomized trial comparing vinblastine in slow infusion and by bolus i.v. injection in idiopathic thrombocytopenic purpura: a report on 42 patients. Br J Haematol. Mar 1994;86(3):678-80. [Medline].

  49. Emilia G, Morselli M, Luppi M, et al. Long-term salvage therapy with cyclosporin A in refractory idiopathic thrombocytopenic purpura. Blood. Feb 15 2002;99(4):1482-5. [Medline]. [Full Text].

  50. Kuter DJ, Rummel M, Boccia R, Macik BG, Pabinger I, Selleslag D, et al. Romiplostim or standard of care in patients with immune thrombocytopenia. N Engl J Med. Nov 11 2010;363(20):1889-99. [Medline].

  51. Khan LR, Nixon SJ. Laparoscopic splenectomy is a better treatment for adult ITP than steroids--it should be used earlier in patient management. Conclusions of a ten-year follow-up study. Surgeon. Feb 2007;5(1):3-4, 6-8. [Medline].

  52. Rescorla FJ, West KW, Engum SA, Grosfeld JL. Laparoscopic splenic procedures in children: experience in 231 children. Ann Surg. Oct 2007;246(4):683-7; discussion 687-8. [Medline].

  53. Bell WR Jr. Role of splenectomy in immune (idiopathic) thrombocytopenic purpura. Blood Rev. Mar 2002;16(1):39-41. [Medline].

  54. Rodeghiero F, Frezzato M, Schiavotto C, Castaman G, Dini E. Fulminant sepsis in adults splenectomized for idiopathic thrombocytopenic purpura. Haematologica. May-Jun 1992;77(3):253-6. [Medline].

  55. Zarrabi MH, Rosner F. Serious infections in adults following splenectomy for trauma. Arch Intern Med. Jul 1984;144(7):1421-4. [Medline].

  56. Beattie JF, Michelson ML, Holman PJ. Acute babesiosis caused by Babesia divergens in a resident of Kentucky. N Engl J Med. Aug 29 2002;347(9):697-8. [Medline].

  57. Crary SE, Buchanan GR. Vascular complications after splenectomy for hematologic disorders. Blood. Oct 1 2009;114(14):2861-8. [Medline].

  58. Robinette CD, Fraumeni JF Jr. Splenectomy and subsequent mortality in veterans of the 1939-45 war. Lancet. Jul 16 1977;2(8029):127-9. [Medline].

  59. Purcell PL, Crary SE, Adix LM, Alder AC, Buchanan GR. Postsplenectomy vascular complications: Feasibility of studying patients with splenectomy following trauma. Am J Hematol. May 2009;84(5):316-7. [Medline].

  60. George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood. Jul 1 1996;88(1):3-40. [Medline]. [Full Text].

  61. Facon T, Caulier MT, Fenaux P, et al. Accessory spleen in recurrent chronic immune thrombocytopenic purpura. Am J Hematol. Nov 1992;41(3):184-9. [Medline].

  62. Woo JH, Park SH, Park YK, et al. Postsplenectomy recurrence of thrombocytopenia with an accessory spleen. Korean J Intern Med. Sep 2004;19(3):199-201. [Medline]. [Full Text].

  63. Dolan JP, Sheppard BC, DeLoughery TG. Splenectomy for immune thrombocytopenic purpura: surgery for the 21st century. Am J Hematol. Feb 2008;83(2):93-6. [Medline].

  64. Balagué C, Vela S, Targarona EM, et al. Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura: study of clinical and laboratory data. Surg Endosc. Aug 2006;20(8):1208-13. [Medline].

  65. Blanchette VS, Carcao M. Childhood acute immune thrombocytopenic purpura: 20 years later. Semin Thromb Hemost. Dec 2003;29(6):605-17. [Medline].

  66. Cooper N, Evangelista ML, Amadori S, Stasi R. Should rituximab be used before or after splenectomy in patients with immune thrombocytopenic purpura?. Curr Opin Hematol. Nov 2007;14(6):642-6. [Medline].

  67. George JN. Management of immune thrombocytopenia--something old, something new. N Engl J Med. Nov 11 2010;363(20):1959-61. [Medline].

  68. McMillan R, Bussel JB, George JN, Lalla D, Nichol JL. Self-reported health-related quality of life in adults with chronic immune thrombocytopenic purpura. Am J Hematol. Feb 2008;83(2):150-4. [Medline].

  69. Newland A. Thrombopoietin mimetic agents in the management of immune thrombocytopenic purpura. Semin Hematol. Oct 2007;44(4 suppl 5):S35-45. [Medline].

  70. von dem Borne A, Folman C, van den Oudenrijn S, et al. The potential role of thrombopoietin in idiopathic thrombocytopenic purpura. Blood Rev. Mar 2002;16(1):57-9. [Medline].

  71. Bussel JB, Kuter DJ, George JN, et al. AMG 531, a thrombopoiesis-stimulating protein, for chronic ITP. N Engl J Med. Oct 19 2006;355(16):1672-81. [Medline]. [Full Text].

  72. [Best Evidence] Kuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. Feb 2 2008;371(9610):395-403. [Medline].

  73. Jamali F, Lemery S, Ayalew K, Robottom S, Robie-Suh K, Rieves D, et al. Romiplostim for the treatment of chronic immune (idiopathic) thrombocytopenic purpura. Oncology (Williston Park). Jul 2009;23(8):704-9. [Medline].

  74. Bussel JB, Cheng G, Saleh MN, et al. Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura. N Engl J Med. Nov 29 2007;357(22):2237-47. [Medline].

  75. Rice L. Treatment of immune thrombocytopenic purpura: focus on eltrombopag. Biologics. 2009;3:151-7. [Medline].

  76. Cheng G, Saleh MN, Marcher C, et al. Eltrombopag for management of chronic immune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study. Lancet. Jan 29 2011;377(9763):393-402. [Medline].

  77. Mikhael J, Northridge K, Lindquist K, Kessler C, Deuson R, Danese M. Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: A systematic review. Am J Hematol. Jul 16 2009;[Medline].

  78. Ahmed S, Siddiqui AK, Shahid RK, et al. Prognostic variables in newly diagnosed childhood immune thrombocytopenia. Am J Hematol. Dec 2004;77(4):358-62. [Medline]. [Full Text].

  79. Ben-Yehuda D, Gillis S, Eldor A. Clinical and therapeutic experience in 712 Israeli patients with idiopathic thrombocytopenic purpura. Israeli ITP Study Group. Acta Haematol. 1994;91(1):1-6. [Medline].

  80. Bengtson KL, Skinner MA, Ware RE. Successful use of anti-CD20 (rituximab) in severe, life-threatening childhood immune thrombocytopenic purpura. J Pediatr. Nov 2003;143(5):670-3. [Medline].

  81. Bennett CM, Rogers ZR, Kinnamon DD, et al. Prospective phase 1/2 study of rituximab in childhood and adolescent chronic immune thrombocytopenic purpura. Blood. Apr 1 2006;107(7):2639-42. [Medline]. [Full Text].

  82. Bolton-Maggs PH, Moon I. Assessment of UK practice for management of acute childhood idiopathic thrombocytopenic purpura against published guidelines. Lancet. Aug 30 1997;350(9078):620-3. [Medline].

  83. Braendstrup P, Bjerrum OW, Nielsen OJ, et al. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adult refractory idiopathic thrombocytopenic purpura. Am J Hematol. Apr 2005;78(4):275-80. [Medline]. [Full Text].

  84. Bruin M, Bierings M, Uiterwaal C, et al. Platelet count, previous infection and FCGR2B genotype predict development of chronic disease in newly diagnosed idiopathic thrombocytopenia in childhood: results of a prospective study. Br J Haematol. Dec 2004;127(5):561-7. [Medline].

  85. Bussel JB. Recent advances in the treatment of idiopathic thrombocytopenic purpura: the anti-D clinical experience. Semin Hematol. Jan 1998;35(1 suppl 1):1-4. [Medline].

  86. Chang M, Nakagawa PA, Williams SA, et al. Immune thrombocytopenic purpura (ITP) plasma and purified ITP monoclonal autoantibodies inhibit megakaryocytopoiesis in vitro. Blood. Aug 1 2003;102(3):887-95. [Medline]. [Full Text].

  87. Cines DB, Bussel JB, McMillan RB, Zehnder JL. Congenital and acquired thrombocytopenia. Hematology Am Soc Hematol Educ Program. 2004;390-406. [Medline]. [Full Text].

  88. Clark AL. Clinical uses of intravenous immunoglobulin in pregnancy. Clin Obstet Gynecol. Jun 1999;42(2):368-80. [Medline].

  89. Cooper N, Stasi R, Cunningham-Rundles S, et al. The efficacy and safety of B-cell depletion with anti-CD20 monoclonal antibody in adults with chronic immune thrombocytopenic purpura. Br J Haematol. Apr 2004;125(2):232-9. [Medline].

  90. Cortelazzo S, Finazzi G, Buelli M, et al. High risk of severe bleeding in aged patients with chronic idiopathic thrombocytopenic purpura. Blood. Jan 1 1991;77(1):31-3. [Medline]. [Full Text].

  91. Davis PW, Williams DA, Shamberger RC. Immune thrombocytopenia: surgical therapy and predictors of response. J Pediatr Surg. Apr 1991;26(4):407-12; discussion 412-3. [Medline].

  92. Dixon R, Rosse W, Ebbert L. Quantitative determination of antibody in idiopathic thrombocytopenic purpura. Correlation of serum and platelet-bound antibody with clinical response. N Engl J Med. Jan 30 1975;292(5):230-6. [Medline].

  93. Duhem C, Dicato MA, Ries F. Side-effects of intravenous immune globulins. Clin Exp Immunol. Jul 1994;97 suppl 1:79-83. [Medline]. [Full Text].

  94. Emilia G, Longo G, Luppi M, et al. Helicobacter pylori eradication can induce platelet recovery in idiopathic thrombocytopenic purpura. Blood. Feb 1 2001;97(3):812-4. [Medline]. [Full Text].

  95. Emilia G, Luppi M, Morselli M, et al. Helicobacter pylori infection and idiopathic thrombocytopenic purpura. Br J Haematol. Sep 2002;118(4):1198-9. [Medline].

  96. Engelfriet CP, Reesink HW, Bussel J, et al. The treatment of patients with autoimmune thrombocytopenia with intravenous IgG-anti-D. Vox Sang. 1999;76(4):250-5. [Medline].

  97. Fehr J, Hofmann V, Kappeler U. Transient reversal of thrombocytopenia in idiopathic thrombocytopenic purpura by high-dose intravenous gamma globulin. N Engl J Med. May 27 1982;306(21):1254-8. [Medline].

  98. Friedman RL, Fallas MJ, Carroll BJ, Hiatt JR, Phillips EH. Laparoscopic splenectomy for ITP. The gold standard. Surg Endosc. Oct 1996;10(10):991-5. [Medline].

  99. Gasbarrini A, Franceschi F, Tartaglione R, et al. Regression of autoimmune thrombocytopenia after eradication of Helicobacter pylori. Lancet. Sep 12 1998;352(9131):878. [Medline].

  100. Gernsheimer T. Pathophysiology and thrombokinetics in autoimmune thrombocytopenia. Blood Rev. Mar 2002;16(1):7-8. [Medline].

  101. Grosfeld JL, Naffis D, Boles ET Jr, Newton WA Jr. The role of splenectomy in neonatal idiopathic thrombocytopenic purpura. J Pediatr Surg. Apr 1970;5(2):166-71. [Medline].

  102. Hashino S, Mori A, Suzuki S, et al. Platelet recovery in patients with idiopathic thrombocytopenic purpura after eradication of Helicobacter pylori. Int J Hematol. Feb 2003;77(2):188-91. [Medline].

  103. Hong F, Ruiz R, Price H, et al. Safety profile of WinRho anti-D. Semin Hematol. Jan 1998;35(1 suppl 1):9-13. [Medline].

  104. Houwerzijl EJ, Blom NR, van der Want JJ, et al. Ultrastructural study shows morphologic features of apoptosis and para-apoptosis in megakaryocytes from patients with idiopathic thrombocytopenic purpura. Blood. Jan 15 2004;103(2):500-6. [Medline]. [Full Text].

  105. Jacobs P, Wood L, Novitzky N. Intravenous gammaglobulin has no advantages over oral corticosteroids as primary therapy for adults with immune thrombocytopenia: a prospective randomized clinical trial. Am J Med. Jul 1994;97(1):55-9. [Medline].

  106. Jarque I, Andreu R, Llopis I, et al. Absence of platelet response after eradication of Helicobacter pylori infection in patients with chronic idiopathic thrombocytopenic purpura. Br J Haematol. Dec 2001;115(4):1002-3. [Medline].

  107. Karpatkin S. Autoimmune (idiopathic) thrombocytopenic purpura. Lancet. May 24 1997;349(9064):1531-6. [Medline].

  108. Karpatkin S. Autoimmune thrombocytopenias. Autoimmunity. Jun 2004;37(4):363-8. [Medline].

  109. Kohda K, Kuga T, Kogawa K, et al. Effect of Helicobacter pylori eradication on platelet recovery in Japanese patients with chronic idiopathic thrombocytopenic purpura and secondary autoimmune thrombocytopenic purpura. Br J Haematol. Aug 2002;118(2):584-8. [Medline].

  110. Kühne T, Buchanan GR, Zimmerman S, et al. A prospective comparative study of 2540 infants and children with newly diagnosed idiopathic thrombocytopenic purpura (ITP) from the Intercontinental Childhood ITP Study Group. J Pediatr. Nov 2003;143(5):605-8. [Medline].

  111. Lalayanni C, Stavroyianni N, Saloum R, Tsompanakou A, Anagnostopoulos A. Rituximab is effective for selected patients with chronic steroid-refractory immune thrombocytopenic purpura. Hematology. Aug 2004;9(4):287-9. [Medline].

  112. Lightsey AL Jr, McMillan R, Koenig HM. Childhood idiopathic thrombocytopenic purpura. Aggressive management of life-threatening complications. JAMA. May 19 1975;232(7):734-6. [Medline].

  113. McMillan R, Durette C. Long-term outcomes in adults with chronic ITP after splenectomy failure. Blood. Aug 15 2004;104(4):956-60. [Medline]. [Full Text].

  114. McMillan R, Longmire RL, Yelenosky R, Smith RS, Craddock CG. Immunoglobulin synthesis in vitro by splenic tissue in idiopathic thrombocytopenic purpura. N Engl J Med. Mar 30 1972;286(13):681-4. [Medline].

  115. Narat S, Gandla J, Hoffbrand AV, Hughes RG, Mehta AB. Rituximab in the treatment of refractory autoimmune cytopenias in adults. Haematologica. Sep 2005;90(9):1273-4. [Medline]. [Full Text].

  116. Nugent DJ. Childhood immune thrombocytopenic purpura. Blood Rev. Mar 2002;16(1):27-9. [Medline].

  117. Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Poulin EC. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). Surg Endosc. Jan 2003;17(1):95-8. [Medline].

  118. Provan D, Newland A. Idiopathic thrombocytopenic purpura in adults. J Pediatr Hematol Oncol. Dec 2003;25 suppl 1:S34-8. [Medline].

  119. Raj K, Narayanan S, Augustson B, et al. Rituximab is effective in the management of refractory autoimmune cytopenias occurring after allogeneic stem cell transplantation. Bone Marrow Transplant. Feb 2005;35(3):299-301. [Medline].

  120. Roganovic J. Rituximab treatment in refractory idiopathic thrombocytopenic purpura in children. Eur J Pediatr. May 2005;164(5):334. [Medline].

  121. Rushin J, Rumsey DH, Ewing CA, Sandler SG. Detection of multiple passively acquired alloantibodies following infusions of IV Rh immune globulin. Transfusion. May 2000;40(5):551-4. [Medline].

  122. Sailler L. Rituximab off label use for difficult-to-treat auto-immune diseases: reappraisal of benefits and risks. Clin Rev Allergy Immunol. Feb 2008;34(1):103-10. [Medline].

  123. Salama A, Mueller-Eckhardt C, Kiefel V. Effect of intravenous immunoglobulin in immune thrombocytopenia. Lancet. Jul 23 1983;2(8343):193-5. [Medline].

  124. Sandler SG. Intravenous Rh immune globulin for treating immune thrombocytopenic purpura. Curr Opin Hematol. Nov 2001;8(6):417-20. [Medline].

  125. Sandler SG, Mallory D, Trimble J, Nance ST. Intravenous anti-D treatment for immune thrombocytopenic purpura. Blood. Apr 1 1998;91(7):2624-5. [Medline]. [Full Text].

  126. Savasman CM, Sandler SG. Serologic aspects of treating immune thrombocytopenic purpura using intravenous Rh immune globulin. Immunohematology. 2001;17(4):106-10. [Medline].

  127. Scaradavou A, Woo B, Woloski BM, et al. Intravenous anti-D treatment of immune thrombocytopenic purpura: experience in 272 patients. Blood. Apr 15 1997;89(8):2689-700. [Medline]. [Full Text].

  128. Shad AT, Gonzalez CE, Sandler SG. Treatment of immune thrombocytopenic purpura in children : current concepts. Paediatr Drugs. 2005;7(5):325-36. [Medline].

  129. Stasi R, Pagano A, Stipa E, Amadori S. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura. Blood. Aug 15 2001;98(4):952-7. [Medline]. [Full Text].

  130. Stasi R, Provan D. Management of immune thrombocytopenic purpura in adults. Mayo Clin Proc. Apr 2004;79(4):504-22. [Medline].

  131. Stasi R, Stipa E, Forte V, Meo P, Amadori S. Variable patterns of response to rituximab treatment in adults with chronic idiopathic thrombocytopenic purpura. Blood. May 15 2002;99(10):3872-3. [Medline]. [Full Text].

  132. Taube T, Schmid H, Reinhard H, von Stackelberg A, Overberg US. Effect of a single dose of rituximab in chronic immune thrombocytopenic purpura in childhood. Haematologica. Feb 2005;90(2):281-3. [Medline]. [Full Text].

  133. Veneri D, Franchini M, Gottardi M, et al. Efficacy of Helicobacter pylori eradication in raising platelet count in adult patients with idiopathic thrombocytopenic purpura. Haematologica. Nov 2002;87(11):1177-9. [Medline]. [Full Text].

  134. Wanachiwanawin W, Piankijagum A, Sindhvananda K, et al. Emergency splenectomy in adult idiopathic thrombocytopenic purpura. A report of seven cases. Arch Intern Med. Jan 1989;149(1):217-9. [Medline].

  135. Ware RE, Zimmerman SA. Anti-D: mechanisms of action. Semin Hematol. Jan 1998;35(1 suppl 1):14-22. [Medline].

  136. Watson DI, Coventry BJ, Chin T, Gill PG, Malycha P. Laparoscopic versus open splenectomy for immune thrombocytopenic purpura. Surgery. Jan 1997;121(1):18-22. [Medline].

  137. Zimmerman SA, Malinoski FJ, Ware RE. Immunologic effects of anti-D (WinRho-SD) in children with immune thrombocytopenic purpura. Am J Hematol. Feb 1998;57(2):131-8. [Medline]. [Full Text].

 
Previous
Next
 
Peripheral blood smear from a patient with immune thrombocytopenic purpura (ITP) illustrates a decreased number of platelets, a normal-appearing neutrophil, and erythrocytes. ITP is diagnosed by excluding other diseases; therefore, the absence of other findings from the peripheral smear is at least as important as the findings are observed. This smear demonstrates the absence of immature leukocytes (as in leukemia) and fragmented erythrocytes (as in thrombotic thrombocytopenic purpura) and no clumps of platelets (as in pseudothrombocytopenia).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.