Thrombocytopenia

Thrombocytopenia
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ThrombocytopeniaClassification and external resources
ICD-10
D69.6, P61.0
ICD-9
287.3, 287.4, 287.5
OMIM
188000 313900
DiseasesDB
27522
MedlinePlus
000586
MeSH
D013921

Thrombocytopenia (or -paenia, or thrombopenia in short) is the presence of relatively few platelets in blood.

Generally speaking, in humans, a normal platelet count ranges from 150,000 and 450,000 per mm3 (microlitre).[1] These limits, however, are determined by the 2.5th lower and upper percentile, and a deviation does not necessarily imply any form of disease. The number of platelets in a blood sample also decreases rather quickly with time and a low platelet count may be caused by a delay between sampling and analysis.
Contents[hide]
1 Signs and symptoms
2 Diagnosis
3 Causes
3.1 Decreased production
3.2 Increased destruction
3.3 Medication-induced
4 Treatment
4.1 Thrombotic thrombocytopenic purpura (TTP)
4.2 Idiopathic thrombocytopenic purpura (ITP)
4.3 Heparin-induced thrombocytopenia and thrombosis (HITT)
4.4 Congenital amegakaryocytic thrombocytopenia (CAMT)
5 References
6 External links
//

Signs and symptoms
Often, low platelet levels do not lead to clinical problems; rather, they are picked up on a routine full blood count (or CBC, complete blood count). Occasionally, there may be bruising, particularly purpura in the forearms, nosebleeds and/or bleeding gums.
It is vital that a full medical history is elicited, to ensure the low platelet count is not due to a secondary process. It is also important to ensure that the other blood cell types red blood cells, and white blood cells, are not also suppressed.

Diagnosis
Laboratory tests might include: full blood count, liver enzymes, renal function, vitamin B12 levels, folic acid levels, erythrocyte sedimentation rate, and peripheral blood smear.
If the cause for the low platelet count remains unclear, bone marrow biopsy is often undertaken, to differentiate whether the low platelet count is due to decreased production or peripheral destruction.

Causes
Decreased platelet counts can be due to a number of disease processes:

Decreased production
vitamin B12 or folic acid deficiency
leukemia or myelodysplastic syndrome
Decreased production of thrombopoietin by the liver in liver failure.
Sepsis, systemic viral or bacterial infection
Dengue fever can cause thrombocytopenia by direct infection of bone marrow megakaryocytes as well as immunological shortened platelet survival
Hereditary syndromes
Congenital Amegakaryocytic Thrombocytopenia (CAMT)
Thrombocytopenia absent radius syndrome
Fanconi anemia
Bernard-Soulier syndrome, associated with large platelets
May-Hegglin anomaly, the combination of thrombocytopenia, pale-blue leuckocyte inclusions, and giant platelets
Grey platelet syndrome
Alport syndrome

Increased destruction
idiopathic thrombocytopenic purpura (ITP)
thrombotic thrombocytopenic purpura (TTP)
hemolytic-uremic syndrome (HUS)
disseminated intravascular coagulation (DIC)
paroxysmal nocturnal hemoglobinuria (PNH)
antiphospholipid syndrome
systemic lupus erythematosus (SLE)
post transfusion purpura
neonatal alloimmune thrombocytopenia (NAITP)
Splenic sequestration of platelets due to hypersplenism
Dengue fever has been shown to cause shortened platelet survival and immunological platelet destruction
HIV Scaradavou A (2002). "HIV-related thrombocytopenia". Blood Rev. 16 (1): 73–6. doi:10.1054/blre.2001.0188. PMID 11914001, http://linkinghub.elsevier.com/retrieve/pii/S0268960X01901882.

Medication-induced
The most comprehensive list of thrombocytopenia-inducing medications is maintained by Dr. James George at Ohio State University at this website, though last updated in 2004. A small subset of drug-induced thrombocytopenia culprits:
Drug name
Heparin
Valproic acid
Quinidine
Abciximab
Sulfonamide antibiotics
Interferons
Measles-mumps-rubella vaccine
Glycoprotein IIb/IIIa inhibitors
Clopidogrel
Vancomycin [2][3]
Linezolid
Famotidine
Mebeverine
Tinidazole/Metronidazole
Direct myelosuppression
Valproic acid
Methotrexate
Carboplatin
Interferon
Other chemotherapy drugs
Immunological platelet destruction
Drug binds Fab portion of an antibody. The classic example of this mechanism is the quinidine group of drugs. The Fc portion of the antibody molecule is not involved in the binding process.
Drug binds to Fc, and drug-antibody complex binds and activates platelets. Heparin induced thrombocytopenia (HIT) is the classic example of this phenomenon. In HIT, the heparin-antibody-platelet factor 4 (PF4) complex binds to Fc receptors on the surface of the platelet. Since Fc portion of the antibody is bound to the platelets, they are not available to the Fc receptors of the reticulo-endothelial cells, so therefore this system cannot destroy platelets as usual. This may explain why severe thrombocytopenia is not a common feature of HIT.
Heparin-induced thrombocytopenia (HIT or white clot syndrome): this is a rare but serious condition that may occur in a hospitalized population. The most common clinical setting for HIT is in postoperative coronary artery bypass graft recipients, who may receive large quantities of heparin during surgery. HIT typically occurs about a week after exposure to heparin. The heparin-PF4 antibody complex will activate the platelets, and this can often lead to thrombosis. The term HITT, where the last T stands for thrombosis, denotes the concept that heparin-induced thrombocytopenia often is associated with thrombosis.

Treatment
Treatment is guided by etiology and disease severity. The main concept in treating thrombocytopenia is to eliminate the underlying problem, whether that means discontinuing suspected drugs that cause thrombocytopenia, or treating underlying sepsis. Diagnosis and treatment of serious thrombocytopenia is usually directed by a hematologist.
Specific treatment plans often depend on the underlying etiology of the thrombocytopenia.

Thrombotic thrombocytopenic purpura (TTP)
Treatment of thrombotic thrombocytopenic purpura is a medical emergency, since the hemolytic anemia and platelet activation can lead to renal failure and changes in the level of consciousness. Treatment of TTP was revolutionized in the 1980s with the application of plasmapheresis. According to the Furlan-Tsai hypothesis [4] [5] , this treatment theoretically works by removing antibodies directed against the von Willebrand factor cleaving protease, ADAMTS-13. The plasmapheresis procedure also adds active ADAMTS-13 protease proteins to the patient, restoring a more physiological state of von Willebrand factor multimers. Patients with persistent antibodies against ADAMTS-13 do not always manifest TTP, and these antibodies alone are not sufficient to explain the how plasmapheresis treats TTP.

Idiopathic thrombocytopenic purpura (ITP)
Main article: Idiopathic thrombocytopenic purpura
Many cases of ITP can be left untreated, and spontaneous remission (especially in children) is not uncommon. However, counts of under 50,000 are usually monitiored with regular blood tests, and those with counts of under 10,000 are usually treated, as the risk of serious spontaneous bleeding is high with a platelet count this low. Any patient experiencing severe bleeding symptoms is also usually treated. The threshold for treating ITP has decreased since the 1990s, and hematologists recognize that patients rarely spontaneously bleed with platelet counts greater than 10,000—though there are documented exceptions to this observation.
Treatments for ITP include:
Prednisone and other corticosteroids
Intravenous immune globulin
Splenectomy
Danazol
Rituximab
Romiplostim
Thrombopoetin analogues have been tested extensively for the treatment of ITP. These agents had previously shown promise but had been found to stimulate antibodies against endogenous thrombopoeitin or lead to thrombosis.
Romiplostim (trade name Nplate, formerly AMG 531) was found to be safe and effective for the treatment of ITP in refractory patients, especially those who relapsed following splenectomy.[6][7][8] Romiplostim is a peptide that bears no sequence homology with endogenous human thrombopoeitin, so it is not as likely to lead to neutralizing antibodies as previous peptide thrombopoeitin analogues. [9]

Heparin-induced thrombocytopenia and thrombosis (HITT)
Main article: Heparin-induced thrombocytopenia
Discontinuation of heparin is critical in a case of HITT. Beyond that, however, clinicians generally treat to avoid a thrombosis, and patients started directly on warfarin after a diagnosis of HITT are at excess risk of venous limb gangrene. For this reason, patients are usually treated with a type of blood thinner called a direct thrombin inhibitor such as the FDA-approved lepirudin or argatroban. Other blood thinners sometimes used in this setting that are not FDA-approved for treatment of HITT include bivalirudin and fondaparinux. Platelet transfusions are not a routine component of the treatment of HITT, since thrombosis, not bleeding, is the usual associated problem in this illness.

Congenital amegakaryocytic thrombocytopenia (CAMT)
Congenital amegakaryocytic thrombocytopenia (CAMT) is a rare inherited disorder. The primary manifestations are thrombocytopenia and megakaryocytopenia, or low numbers of platelets and megakaryocytes. There is an absence of megakaryocytes in the bone marrow with no associated physical abnormalities.[10] The cause for this disorder appears to be a mutation in the gene for the TPO receptor, c-mpl, despite high levels of serum TPO.[11][12] In addition, there may be abnormalities with the central nervous system including the cerebrum and cerebellum which could cause symptoms.[11] The primary treatment for CAMT is bone marrow transplantation.
Bone Marrow/Stem Cell Transplant is the only thing that ultimately cures this genetic disease. Frequent platelet transfusions are required to keep the patient from bleeding to death until transplant is done, although this is not always the case.
One of the few non Medical Research related sources on the web with some information on CAMT is;
CAMT Specific Infant Bone Marrow Transplant Journal
There appears to be no generic resource for CAMT patients on the web, and this is potentially due to the rariety of the disease.

References
^ "Platelet count aka thrombocyte count". Lab Tests Online UK (2004-05-28). Retrieved on 2008-05-22.
^ Howard C, Adams L, Admire J, Chu M, Alred G (1997). "Vancomycin-induced thrombocytopenia: a challenge and rechallenge". Ann Pharmacother 31 (3): 315–8. PMID 9066938.
^ Von Drygalski A, Curtis BR, Bougie DW, et al (2007). "Vancomycin-induced immune thrombocytopenia". N. Engl. J. Med. 356 (9): 904–10. doi:10.1056/NEJMoa065066. PMID 17329697, http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17329697&promo=ONFLNS19.
^ Furlan M, Lämmle B (2001). "Aetiology and pathogenesis of thrombotic thrombocytopenic purpura and haemolytic uraemic syndrome: the role of von Willebrand factor-cleaving protease". Best Pract Res Clin Haematol 14 (2): 437–54. doi:10.1053/beha.2001.0142. PMID 11686108.
^ Tsai H (2003). "Advances in the pathogenesis, diagnosis, and treatment of thrombotic thrombocytopenic purpura". J Am Soc Nephrol 14 (4): 1072–81. doi:10.1097/01.ASN.0000060805.04118.4C. PMID 12660343.
^ Bussel J, Kuter D, George J, McMillan R, Aledort L, Conklin G, Lichtin A, Lyons R, Nieva J, Wasser J, Wiznitzer I, Kelly R, Chen C, Nichol J (2006). "AMG 531, a thrombopoiesis-stimulating protein, for chronic ITP". N Engl J Med 355 (16): 1672–81. doi:10.1056/NEJMoa054626. PMID 17050891.
^ AMGEN (2008-03-12). "Press release: Amgen Statement on Successful Outcome of Romiplostim Panel Meeting", Business Wire via drugs.com. Retrieved on 22 May 2008.
^ "US FDA panel backs Amgen's Nplate against ITP", Reuters (2008-03-12). Retrieved on 22 May 2008.
^ Broudy V, Lin N (2004). "AMG531 stimulates megakaryopoiesis in vitro by binding to Mpl". Cytokine 25 (2): 52–60. doi:10.1016/j.cyto.2003.05.001. PMID 14693160.
^ Freedman MH, Estrov Z (1990). "Congenital amegakaryocytic thrombocytopenia: an intrinsic hematopoietic stem cell defect". Am. J. Pediatr. Hematol. Oncol. 12: 225–230.
^ a b Ihara K, Ishii E, Eguchi M, Takada H, Suminoe A, Good RA, Hara T (1999). "Identification of mutations in the c-mpl gene in congenital amegakaryocytic thrombocytopenia". Proc. Natl. Acad. Sci. 96: 3133–6. doi:10.1073/pnas.96.6.3132. PMID 10077649.
^ Ballmaier M, Germeshausen M, Schulze H, Cherkaoui K, Lang S, Gaudig A, Krukemeier S, Eilers M, Strauss G, Welte K (2001). "C-mpl mutations are the cause of congenital amegakaryocytic thrombocytopenia". Blood. 97: 139–46. doi:10.1182/blood.V97.1.139. PMID 11133753.

External links
11-133b. at Merck Manual of Diagnosis and Therapy Professional Edition
Thrombocytopenia Forum
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v • d • ePathology: hematology · myeloid hematologic disease (primarily D50-D77 · 280-289)
RBCs/hemoglobinopathy
+
Polycythemia · Macrocytosis
·
Anemia
Nutritional
Iron deficiency anemia (Plummer-Vinson syndrome) · Megaloblastic anemia (Pernicious anemia)
Hemolytic
Hereditary
enzyme: G6PD Deficiency · Pyruvate kinase deficiency · Triosephosphate isomerase deficiency
hemoglobin: Thalassemia · Sickle-cell disease/traitmembrane: Hereditary spherocytosis · Hereditary elliptocytosis · Hereditary stomatocytosis
Acquired
Autoimmune (Warm, Cold) · HUS · MAHA · PNH · PCH · Myelophthisic
Aplastic
Acquired PRCA · Diamond-Blackfan anemia · Fanconi anemia · Sideroblastic anemia
Blood tests
MCV (Normocytic, Microcytic, Macrocytic) · MCHC (Normochromic, Hypochromic)
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Methemoglobinemia
Coagulation/platelets/coagulopathy/bleeding diathesis
+
Hypercoagulability
primary: Antithrombin III deficiency · Protein C deficiency/Activated protein C resistance/Protein S deficiency/Factor V Leiden · Hyperprothrombinemiaacquired: DIC (Congenital afibrinogenemia, Purpura fulminans) · autoimmune (Antiphospholipid)
Other
Essential thrombocytosis
·
clotting factor: Hemophilia (A/VIII, B/IX, C/XI) • Von Willebrand disease • Hypoprothrombinemia/II · XIII
platelet function: Bernard-Soulier syndrome · Glanzmann's thrombasthenia · Hermansky-Pudlak syndrome · Gray platelet syndrome · May Hegglin anomaly · Pelger-Huet anomaly
Purpura: Henoch-Schönlein · TP · ITP (Evans syndrome) · TTPThrombocytopenia (Heparin-induced thrombocytopenia)
Monocytes/macrophages
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Histiocytosis
WHO-I (Langerhans cell histiocytosis)
WHO-II/non-Langerhans-cell (Juvenile xanthogranuloma, Hemophagocytic lymphohistiocytosis)WHO-III/malignant (Acute monocytic leukemia, Malignant histiocytosis, Erdheim-Chester disease)
Other
Chronic granulomatous disease-cytosis: Monocytosis
·
-penia: Monocytopenia
Granulocytes
+
-cytosis: granulocytosis (Neutrophilia, Eosinophilia, Basophilia)
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-penia: Granulocytopenia/agranulocytosis (Neutropenia/Kostmann syndrome · Eosinopenia · Basopenia)
See also hematological malignancy and immune disorders