Evaluation of thrombocytopenia

Diseases

Summary

Thrombocytopenia is defined as a low circulating platelet count (<150,000 per microliter). Platelet life span is normally approximately 5 days, with continual renewal.

Thrombocytopenia results from either a reduced production of platelets in the bone marrow, increased clearance, sequestering of platelets in the spleen, or dilution.

The differential diagnosis for a patient with new thrombocytopenia is broad and includes primary bone marrow disorders, chronic liver disease, infection, drug-related adverse effects, occult malignancy, and autoimmune/rheumatologic conditions.

Epidemiology

The causes of thrombocytopenia are diverse, making epidemiologic generalizations difficult. However, immune thrombocytopenia (ITP) increases with age and has a slight female preponderance.[1] [2] The apparent appearance of ITP in other patient groups should prompt a high index of suspicion for an alternate diagnosis: for example, non-Hodgkin lymphoma, drug effect, or myelodysplastic syndrome. ITP has an estimated incidence of approximately 2 to 5 cases per 100,000 in the general population.[1] [2] [3]

Investigation

A complete history, physical exam, review of the CBC, and peripheral smear are necessary to narrow down the differential diagnosis of thrombocytopenia. It is important to exclude artifact or pseudothrombocytopenia.[4]

Bone marrow biopsy is performed if all other studies are inconclusive.

Primary ITP is diagnosed when there is no identifiable underlying condition following comprehensive patient evaluation.[4]

Library

Fundoscopy (left eye) showing area of CMV retinitis inferonasally involving the vascular arcades and the optic disk, associated with vasculitis, and flame hemorrhages
Bilateral hilar adenopathy, associated with sarcoidosis
A diagnostic Reed-Sternberg cell is seen in the center of the image
Thin-film Giemsa-stained micrographs showing ring-form Plasmodium vivax and P falciparum trophozoites
Peripheral blood smear showing leukoerythroblastic reaction: teardrop RBCs (black arrows), and myelocyte (red arrow) and promyelocyte (blue arrow)

Citations

Key Articles

Provan D, Arnold DM, Bussel JB, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019 Nov 26;3(22):3780-817.[Abstract][Full Text]
Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood. 2017 Nov 23;130(21):2271-7.[Abstract][Full Text]
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 207: thrombocytopenia in pregnancy. Obstet Gynecol. 2019 Mar (reaffirmed 2022);133(3):e181-93.[Abstract]
Cooper N, Ghanima W. Immune thrombocytopenia. N Engl J Med. 2019 Sep 5;381(10):945-55.[Abstract][Full Text]
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143.[Full Text]

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