History

Focus on the symptoms of bleeding (eg, type, severity, duration) and on symptoms that may exclude other causes of thrombocytopenia. Elicit risk factors for HIV and systemic symptoms linked to other illnesses or to medications (eg, heparin, alcohol, quinidine/quinine, sulfonamides) that may cause thrombocytopenia.

Medications can be a common etiology for inducing thrombocytopenia, and patients should have their medications carefully reviewed. One study used three distinct methods to document drugs that may be associated with drug-induced immune thrombocytopenia (DITP).^{[5, 6]}Approximately 1500 drugs are associated with thrombocytopenia, but, using this analysis, 24 drugs had evidence of causing thrombocytopenia by all three methods.

Address risk factors for increased bleeding, such as GI disease, CNS disease, urologic disease, or active lifestyle, as these may determine the aggressiveness of management.

Onset of childhood ITP is typically abrupt, and often occurs several weeks after viral illness or live virus immunization. In adults, onset is typically gradual. Common signs include the following:

Purpura
Menorrhagia
Epistaxis
Gingival bleeding
Bruising tendency

Limited data are available on the recurrent form of the disease. One study showed a 6% prevalence of recurrent ITP with most patients (69%) having only one recurrence. Though one third of patients had their recurrent episode within 3 months of their initial one, the remainder of patients had at least a 3-month interval between episodes.

Physical Examination

Evaluate the type and the severity of bleeding and try to exclude other causes of bleeding. Seek evidence of liver disease, thrombosis, autoimmune diseases (eg, nephritis, cutaneous vasculitis, arthritis), and infection, particularly HIV.

Common physical findings include the following:

Nonpalpable petechiae, which mostly occur in dependent regions
Hemorrhagic bullae on mucous membranes
Purpura
Gingival bleeding
Signs of GI bleeding
Menometrorrhagia, menorrhagia
Retinal hemorrhages
Evidence of intracranial hemorrhage, with possible neurologic symptoms
Nonpalpable spleen: The prevalence of palpable spleen in patients with ITP is approximately the same as that in the non-ITP population (ie, 3% in adults, 12% in children).
Spontaneous bleeding when platelet count is less than 20,000/mm ³

Differential Diagnoses

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