Diagnostic Considerations

Common differential diagnoses of immune thrombocytopenia purpura (ITP) and possible alternative causes of thrombocytopenia identified by patient history include the following^[46]:

Previously diagnosed or possible high risk for conditions that may be associated with ITP (eg, infections such as from HIV, hepatitis C virus, hepatitis B virus), autoimmune/immunodeficiency disorders (common variable immunodeficiency, systemic lupus erythematosus, or antiphospholipid syndrome), and malignancy (eg, lymphoproliferative disorders)
Liver disease (including cirrhosis or portal hypertension)
Splenomegaly
Drugs (prescription or nonprescription), including heparin, alemtuzumab, programmed death–1 inhibitors, abciximab, valproate, alcohol abuse, consumption of quinine (tonic water), exposure to environmental toxins, or chemotherapy
Bone marrow diseases, including myelodysplastic syndromes, leukemias, other malignancies, metastatic disease, myelofibrosis, aplastic anemia, megaloblastic anemia, myelophthisis, and Gaucher disease
Recent transfusions (rare possibility of posttransfusion purpura) and recent vaccinations
Inherited thrombocytopenia - Thrombocytopenia–absent radius syndrome, radioulnar synostosis, congenital amegakaryocytic thrombocytopenia, Wiskott-Aldrich syndrome, MYH9-related disease, Bernard-Soulier syndrome, type IIB von Willebrand disease (vWD), or platelet-type VWD
Other thrombocytopenic disorders (eg, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, Evans syndrome)

Differential Diagnoses

Workup

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Media Gallery

Peripheral blood smear from a patient with immune thrombocytopenia (ITP) shows a decreased number of platelets, a normal-appearing neutrophil, and normal-appearing 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 observed findings. 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).

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Table 1. Bleeding scale for pediatric patients with ITP

Table 1. Bleeding scale for pediatric patients with ITP

Grade	Bleeding	Management approach
Grade 1 (minor)	Minor bleeding, few petechiae (≤100 total) and/or ≤5 small bruises (≤3 cm in diameter), no mucosal bleeding	Consent for observation
Grade 2 (mild)	Mild bleeding, many petechiae (>100 total) and/or >5 large bruises (>3 cm in diameter), no mucosal bleeding	Consent for observation
Grade 3 (moderate)	Moderate bleeding, overt mucosal bleeding, troublesome lifestyle	Intervention to reach grade 1 or 2
Grade 4 (severe)	Severe bleeding, mucosal bleeding leading to decrease in Hb > 2 g/dL or suspected internal hemorrhage	Intervention

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Author

Craig M Kessler, MD, MACP 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: Received honoraria from NovoNordisk for consulting; Received grant/research funds from NovoNordisk for other; Received honoraria from Baxter-Immuno for consulting; Received honoraria from Octapharma for speaking and teaching; Received grant/research funds from Octapharma for none; Received consulting fee from Amgen for consulting; Received honoraria from Bayer for review panel membership.

Coauthor(s)

Hira Latif, MD Assistant Professor, Division of Hematology/Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center

Hira Latif, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, International Society on Thrombosis and Haemostasis, Pakistan Medical and Dental Council

Disclosure: Nothing to disclose.

Julia M Cunningham, MD Assistant Professor of Medicine, Division of Hematology and Oncology, Attending Physician in Hematology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center

Julia M Cunningham, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Society of Hematology, Hemostasis and Thrombosis Research Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald A Sacher, MD, FRCPC, DTM&H Professor Emeritus of Internal Medicine and Hematology/Oncology, Emeritus Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MD, FRCPC, DTM&H 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, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Srikanth Nagalla, MD, MS, FACP Chief of Benign Hematology, Miami Cancer Institute, Baptist Health South Florida; Clinical Professor of Medicine, Florida International University, Herbert Wertheim College of Medicine

Srikanth Nagalla, MD, MS, FACP is a member of the following medical societies: American Society of Hematology, Association of Specialty Professors

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Alexion; Alnylam; Kedrion; Sanofi; Dova; Apellis; Pharmacosmos<br/>Serve(d) as a speaker or a member of a speakers bureau for: Sobi; Sanofi; Rigel.

Additional Contributors

S Gerald Sandler, MD, FCAP, FACP Professor Emeritus of Medicine and Pathology, Georgetown University School of Medicine

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

Disclosure: Nothing to disclose.

Immune Thrombocytopenia (ITP) Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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