eMedicine Specialties > Emergency Medicine > Hematology & Oncology

Idiopathic Thrombocytopenic Purpura: Differential Diagnoses & Workup

Author: Michael A Silverman, MD, Instructor of Emergency Medicine, The Johns Hopkins University School of Medicine; Chairman, Department of Emergency Medicine, Harbor Hospital
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Disseminated Intravascular Coagulation
HIV Infection and AIDS
Thrombocytopenic Purpura

Other Problems to Be Considered

Pseudothrombocytopenia (platelet clumping in the presence of ethylenediaminetetraacetic acid [EDTA])
Liver disease
Myelodysplasia
Lymphoproliferative, autoimmune, or infectious diseases
Pregnancy-associated thrombocytopenia
Drug-induced immune thrombocytopenia (alcohol, heparin, quinine/quinidine, sulfonamides)
Infection/sepsis
Acute leukemia
Myelodysplastic syndrome
Malignancy
Megaloblastic anemia
Isoimmune neonatal purpura
Transfusion
Factitious

Workup

Laboratory Studies

  • CBC
    • Isolated thrombocytopenia is the key finding regarding laboratory evaluation.
    • Truly giant platelets on peripheral smear suggest congenital thrombocytopenia.
    • The WBC count and hemoglobin typically are normal, unless severe hemorrhage has occurred.
  • Coagulation studies are normal, and a bleeding time is not useful.

Imaging Studies

  • A CT scan of the head is warranted if concern exists regarding intracranial hemorrhage.

More on Idiopathic Thrombocytopenic Purpura

Overview: Idiopathic Thrombocytopenic Purpura
Differential Diagnoses & Workup: Idiopathic Thrombocytopenic Purpura
Treatment & Medication: Idiopathic Thrombocytopenic Purpura
Follow-up: Idiopathic Thrombocytopenic Purpura
References
[ CLOSE WINDOW ]

References

  1. Williams JA, Boxer LA. Combination therapy for refractory idiopathic thrombocytopenic purpura in adolescents. J Pediatr Hematol Oncol. Mar 2003;25(3):232-5. [Medline].

  2. Pasa S, Altintas A, Cil T, Danis R, Ayyildiz O. The efficacy of rituximab in patients with splenectomized refractory chronic idiopathic thrombocythopenic purpura. J Thromb Thrombolysis. Mar 3 2008;[Medline].

  3. Penalver FJ, Jimenez-Yuste V, Almagro M. Rituximab in the management of chronic immune thrombocytopenic purpura: an effective and safe therapeutic alternative in refractory patients. Ann Hematol. Jun 2006;85(6):400-6. [Medline].

  4. [Best Evidence] Kuter DJ, Bussel JB, Lyons RM, Pullarkat V, Gernsheimer TB, Senecal FM, 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].

  5. Arnold DM, Kelton JG. Current options for the treatment of idiopathic thrombocytopenic purpura. Semin Hematol. Oct 2007;44(4 Suppl 5):S12-23. [Medline].

  6. Blanchette VS, Luke B, Andrew M, et al. A prospective, randomized trial of high-dose intravenous immune globulin G therapy, oral prednisone therapy, and no therapy in childhood acute immune thrombocytopenic purpura. J Pediatr. Dec 1993;123(6):989-95. [Medline].

  7. 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].

  8. 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].

  9. Bulvik S, Winder A, Ben-Tal O. High-dose dexamethasone for splenectomy in patients with idiopathic thrombocytopenic purpura. Haemostasis. Sep-Oct 1998;28(5):256-9. [Medline].

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

  11. 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].

  12. 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):629-632. [Medline].

  13. El Alfy MS, Mokhtar GM, El-Laboudy MA, Khalifa AS. Randomized trial of anti-D immunoglobulin versus low-dose intravenous immunoglobulin in the treatment of childhood chronic idiopathic thrombocytopenic purpura. Acta Haematol. 2006;115(1-2):46-52. [Medline].

  14. Frederiksen H, Schmidt K. The incidence of idiopathic thrombocytopenic purpura in adults increases with age. Blood. Aug 1 1999;94(3):909-13. [Medline].

  15. George JN, El-Harake MA, Aster RH. Thrombocytopenia due to enhanced platelet destruction by immunologic mechanisms. In: Beutler E, Lichtman MA, Coller BS, Kipps TJ, eds. Williams Hematology. 5th ed. New York, NY: McGraw-Hill; 1995:1315-1329.

  16. George JN, el-Harake MA, Raskob GE. Chronic idiopathic thrombocytopenic purpura. N Engl J Med. Nov 3 1994;331(18):1207-11. [Medline].

  17. 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].

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

  19. Heegaard ED, Rosthoj S, Petersen BL, et al. Role of parvovirus B19 infection in childhood idiopathic thrombocytopenic purpura. Acta Paediatr. Jun 1999;88(6):614-7. [Medline].

  20. 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].

  21. Kahn MJ, McCrae KR. Splenectomy in immune thrombocytopenic purpura: recent controversies and long-term outcomes. Curr Hematol Rep. Sep 2004;3(5):317-23. [Medline].

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

  23. Longhurst HJ, O'Grady C, Evans G, et al. Anti-D immunoglobulin treatment for thrombocytopenia associated with primary antibody deficiency. J Clin Pathol. Jan 2002;55(1):64-6. [Medline].

  24. Maloisel F, Andres E, Zimmer J. Danazol therapy in patients with chronic idiopathic thrombocytopenic purpura: long-term results. Am J Med. May 1 2004;116(9):590-4. [Medline].

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

  26. Newland A. Emerging strategies to treat chronic immune thrombocytopenic purpura. Eur J Haematol Suppl. Feb 2008;27-33. [Medline].

  27. Newman GC, Novoa MV, Fodero EM. A dose of 75 microg/kg/d of i.v. anti-D increases the platelet count more rapidly and for a longer period of time than 50 microg/kg/d in adults with immune thrombocytopenic purpura. Br J Haematol. Mar 2001;112(4):1076-8. [Medline].

  28. O'Brien SH, Ritchey AK, Smith KJ. A cost-utility analysis of treatment for acute childhood idiopathic thrombocytopenic purpura (ITP). Pediatr Blood Cancer. Feb 2007;48(2):173-80. [Medline].

  29. Ojima H, Kato T, Araki K. Factors predicting long-term responses to splenectomy in patients with idiopathic thrombocytopenic purpura. World J Surg. Apr 2006;30(4):553-9. [Medline].

  30. Porrata LF, Alberts S, Hook C, et al. Idiopathic thrombocytopenic purpura associated with breast cancer: a case report and review of the current literature. Am J Clin Oncol. Aug 1999;22(4):411-3. [Medline].

  31. Rodeghiero F. First-line therapies for immune thrombocytopenic purpura: re-evaluating the need to treat. Eur J Haematol Suppl. Feb 2008;19-26. [Medline].

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

  33. Schlachta CM, Poulin EC, Mamazza J. Laparoscopic splenectomy for hematologic malignancies. Surg Endosc. Sep 1999;13(9):865-8. [Medline].

  34. Silver RM. Management of idiopathic thrombocytopenic purpura in pregnancy. Clin Obstet Gynecol. Jun 1998;41(2):436-48. [Medline].

  35. Song TB, Lee JY, Kim YH, et al. Low neonatal risk of thrombocytopenia in pregnancy associated with immune thrombocytopenic purpura. Fetal Diagn Ther. Jul-Aug 1999;14(4):216-9. [Medline].

  36. Stasi R, Brunetti M, Pagano A. Pulsed intravenous high-dose dexamethasone in adults with chronic idiopathic thrombocytopenic purpura. Blood Cells Mol Dis. Dec 2000;26(6):582-6. [Medline].

  37. Sukenik-Halevy R, Ellis MH, Fejgin MD. Management of immune thrombocytopenic purpura in pregnancy. Obstet Gynecol Surv. Mar 2008;63(3):182-8. [Medline].

  38. Thude H, Gruhn B, Werner U. Treatment of a patient with chronic immune thrombocytopenic purpura with rituximab and monitoring by flow cytometric analysis. Acta Haematol. 2004;111(4):221-4. [Medline].

  39. Vranou M, Platokouki H, Pergantou H, Aronis S. Recurrent idiopathic thrombocytopenic purpura in childhood. Pediatr Blood Cancer. Apr 17 2008;[Medline].

  40. Watts RG. Idiopathic thrombocytopenic purpura: a 10-year natural history study at the childrens hospital of alabama. Clin Pediatr (Phila). Oct 2004;43(8):691-702. [Medline].

  41. Zeller B, Helgestad J, Hellebostad M. Immune thrombocytopenic purpura in childhood in Norway: a prospective, population-based registration. Pediatr Hematol Oncol. Oct-Nov 2000;17(7):551-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

idiopathic thrombocytopenic purpura, ITP, platelets, primary immune thrombocytopenic purpura, autoimmune thrombocytopenic purpura, thrombocytopenia, hemorrhage, acute ITP, childhood ITP, adult ITP, purpura, isolated thrombocytopenia, splenectomy, platelet count, decrease in number of platelets, increased destruction of platelets, chronic refractory ITP, intracranial hemorrhage, bleeding, menorrhagia, epistaxis, gingival bleeding, recent live virus immunization, recent viral illness, bruising tendency, nephritis,cutaneous vasculitis, arthritis, HIV, petechiae, hemorrhagic bullae, menometrorrhagia, retinal hemorrhages, spontaneous bleeding, immunoglobulin G autoantibodies

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael A Silverman, MD, Instructor of Emergency Medicine, The Johns Hopkins University School of Medicine; Chairman, Department of Emergency Medicine, Harbor Hospital
Michael A Silverman, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.