A DISCUSSION ON THE SIGNIFICANCE OF EARLY BONE MARROW BIOPSY TO A
PATIENT DIAGNOSED TO HAVE IDIOPATHIC THROMBOCYTOPENIC PUPURA:
A CASE REPORT
By: _____________
INTRODUCTION associated with petechiae, ecchymoses,
changes in sleeping habits, myalgia,
Idiopathic thrombocytopenic purpura pallor, dizziness and easy fatigability.
(ITP) is a disease affecting both children There were no signs of active bleeding
and adults. People diagnosed to have like epistaxis or bleeding gums, fever
this disorder should seek immediate and previous viral infection. No
medical attention, as it is one of the consultation done. The patient self-
medical disorders that could claim a medicated with the medications given
person’s life once taken for granted. from her previous admission with no
relief. Persistence of symptoms
prompted consult and subsequent
OBJECTIVES admission. Her past medical history
revealed that she was hypertensive for
This report aims to educate people 10 years. Her highest and usual blood
regarding the importance of seeking pressure were unrecalled, and she was
early medical advice, as well as the maintained on Amlodopine 10mg/tab (1
significance of proper management tablet once a day) and Losartan
(including early bone marrow biopsy) in 50mg/tab (1 tablet once a day). Also,
a patient with blood dyscrasia, like she was a diabetic for more than 10
idiopathic thrombocytopenic purpura. years, maintained on metformin
500mg/tab (1 tablet twice a day). She
has no other diseases like asthma, heart
CASE REPORT disease, renal disease. No known
allergy to both food and drugs and no
A 70-year old female from Taytay, Rizal, previous surgery. She underwent blood
known hypertensive and diabetic, transfusion from her previous
reported severe lower extremity joint admission. Family history was
pains. The patient was previously unremarkable, and no similar illness
admitted due to the same complaint 3 was noted. The personal/social history
weeks prior. She was given folic acid (1 was unremarkable as well. Review of
tablet three times a day), ferrous sulfate systems demonstrated that the patient
tablet (1 tablet three times a day), had weight loss of about 10-15%,
tramadol 500 mg (1 tablet every 8 polyuria, nocturia, polyphagia,
hours). Bone marrow biopsy was polydipsia and palpitations. The general
suggested but was unfortunately not survey in physical examination showed
done. For this admission, history started an elderly female, conscious, coherent,
2 days prior, wherein the patient bedridden, not in cardiorespiratory
experienced severe nonradiating, distress. Vital signs revealed a blood
continuous, lower extremity joint pains pressure of 150/90, cardiac rate of 91,
characterized as squeezing. It was respiratory rate of 18 and temperature of
36C. There is a generalized multiple and serum electrolyes were ordered.
petechiae and ecchymoses, particularly Her vital signs were monitored and
noted on the patient’s back, abdomen record every 4 hours, as well as her
and extremities. Examination of the input and output. On her second
eyes revealed pale palpebral hospital day, she was complaining of
conjunctivae and anicteric sclerae. No lower extremities myalgia and joint
cervical lymphadenopathies noted. pains. No difficulty of breathing, chest
Examination of the cardiovascular pain, abdominal pain or fever noted. Her
revealed adynamic precordium, normal physical examination was essentially
rate regular rhythm, no murmurs. Chest normal except for the generalized
examination revealed symmetrical chest multiple petechiae and ecchymoses,
expansion, clear breath sounds, no and pale palpebral conjunctivae. Her
retractions. Examination of the abdomen management was still the same. On her
revealed flabby, soft, nontender with third hospital day, she still has the same
normoactive bowel sounds. Extremities subjective complaints, except this time,
were grossly normal with full and equal she also complained of constipation.
pulses. During her admission, several Physical examination was still the same.
laboratories were done. On her first Plain abdominal x-ray was done
hospital day, peripheral blood smear revealing generalized adynamic ileus,
showed hypochromic, microcytic red osteophytes in the lumbar vertebrae.
blood cells with ovalocytes and burr Her complete blood count revealed red
forms. White blood cells are in normal blood cell of 2, hemoglobin of 54,
level. No blast cells seen. Platelets are hematocrit of 0.17, platelet of 30, white
inadequate. Complete blood cell blood cell of 18.2, monocyte of 0.067,
revealed red blood cells of 1.5, eosinophil of 0.026, neutrophil of 0.073,
hemoglobin of 48, hematocrit of 0.15, lymphocyte of 0.129. Same
platelets of 30, white blood cell of 16.1, management was done. On her 4 th
monocyte of 0.071, eosinophil of 0.022, hospital day, she still has the same
neutrophil of 0.111, lymphocyte of subjective complaints. Physical
0.792. Serum electrolytes revealed examination revealed, generalized
blood urea nitrogen of 23.67, sodium of petechiae and ecchymoses, pale
140, potassium of 4.6, chloride of 114, palpebral conjunctivae, grade 1 bipedal
creatinine of 250.74. For the edema. Complete blood count revealed
management, she was given PNSS 1L red blood cell of 1.88, hemoglobin of 56,
to run for 100 cc/hr, put on neutropenic hematocrit of 0.17, platelet of 40,
diet, medications include monocyte of 0.072, eosinophil 0.014,
dexamethasone 1 mg/kg, prednisone 4- neutrophil of 0.799, lymphocyte of
8 mg/kg/d, tramadol 500 mg TIV, folic 0.113. Serum electrolytes revealed
acid (1 tablet three times a day), ferrous sodium of 137, potassium of 5.4,
sulfate tablet (1 tablet three times a chloride of 112, creatinine of 245.49,
day), tramadol 500 mg (1 tablet every 8 urea nitrogen of 38.22. Bone marrow
hours) and lactulose. she was aspiration was also done. Same
transfused with 2 units of packed RBC, management was done. On the 4th
properly typed and crossmatched. Daily hospital day, the patient has the same
complete blood count with platelet subjective complaints, now
count, blood urea nitrogen, creatinine, accompanied by abdominal pain and
melena. Physical examination revealed, of the tests. Bone marrow examination
generalized petechiae and ecchymoses, can be reserved for older adults (usually
pale palpebral conjunctivae, grade 1 >60 years) or those who have other
bipedal edema. Same management was signs or laboratory abnormalities not
done. Later that afternoon, she explained by ITP, or in patients who do
complained of difficulty of breathing, not respond to initial therapy. The
hooked to O2 via nasal cannula at 5-6, peripheral blood smear may show large
was intubated and expired despite platelets, with otherwise normal
aggressive resuscitation. morphology. Depending on the bleeding
history, iron deficiency anemia may be
present.
Laboratory testing is performed to
DISCUSSION
evaluate for secondary causes of ITP
Bleeding problems are commonly due to and should include testing for HIV
poorly functioning platelets or decreased infection and hepatitis C (and other
platelets, or loss of certain body proteins infections if indicated); serologic testing
called “clotting factors”. Weakness or for SLE; serum protein electrophoresis
pale skin color are due to poorly and immunoglobulin levels to potentially
functioning red blood cells or decreased detect hypogammaglobulinemia, IgA
number of red blood cells. It is divided deficiency, or monoclonal
into 3. Diseases of platelets, clotting gammopathies; and, if anemia is
factors and red blood cells. Idiopathic or present, direct antiglobulin testing
immune thrombocytopenic purpura (Coombs test) to rule out combined
belong to the diseases of platelets. It is autoimmune hemolytic anemia with ITP
is an acquired disorder leading to (Evans’s syndrome).
immune-mediated destruction of ITP is characterized by mucocutaneous
platelets and possibly inhibition of bleeding and a low, often very low,
platelet release from the platelet count, with otherwise normal
megakaryocyte. In children it is usually peripheral blood cells and smear.
an acute disease, most commonly Patients usually present either with
following an infection, and with a self- ecchymoses and petechiae, or with
limited course. In adults it usually runs a thrombocytopenia incidentally found on
more chronic course. The exact nature a routine CBC. Mucocutaneous
of the immune dysfunction is generally bleeding, such as oral mucosa,
not known. ITP is termed secondary if it gastrointestinal, or heavy menstrual
is associated with an underlying bleeding, may be present. Rarely, life-
disorder; autoimmune disorders, threatening bleeding, including in the
particularly systemic lupus central nervous system, can occur. Wet
erythematosis (SLE), and infections, purpura (blood blisters in the mouth)
such as HIV and hepatitis C, are and retinal hemorrhages may herald life-
common causes. The association of ITP threatening bleeding. Sudden onset of
with Helicobacter pylori infection is small and large bleeding points in the
unclear. skin; often following a virus infection, or
Laboratory testing for antibodies aspirin use. Sometimes, there are
(serologic testing) is usually not helpful nosebleeds or bleeding gums. It is the
due to the low sensitivity and specificity condition of thrombocytopenia of no
known cause. Often it is asymptomatic IgG renders them susceptible to
and can be discovered incidentally, but opsonization and phagocytosis by
a very low platelet count can lead to an splenic macrophages, as well by Kupffer
increased risk of bleeding and purpura. cells in the liver. The IgG autoantibodies
It is diagnosed with a complete blood are also thought to damage
count. In some situations, additional megakaryocytes, the precursor cells to
investigations (such as bone marrow platelets, but this is thought to contribute
biopsy) may be necessary to ensure only slightly to the decrease in platelet
that the platelet count is not decreased numbers. Impaired production of the
due to other reasons. Treatment may glycoprotein hormone thrombopoietin,
not be necessary in mild cases, but very which is the stimulant for platelet
low counts or significant bleeding might production, may be a contributing factor
prompt treatment with steroids, IVIg, to the reduction in circulating platelets.
anti-D Ig, or stronger The stimulus for auto antibody
immunosuppressive drugs. Refractory production in ITP is probably abnormal
ITP (not responsive to conventional T cell activity. For the epidemiology, in
treatment) may require splenectomy. children it is more common in boys. In
Platelet transfusions may be used in middle-aged adults, women are
severe bleeding together with a very low frequently more affected, usually aged
count. Visible symptoms include purpura 30-40. For the prognosis, approximately
and petechiae, especially on the 60-90% of adults respond with
extremities, epistaxis, bleeding at the increased platelet count after treatment
gums, menorrhagia, any of which may with prednisone or prednisone and IV
occur if the platelet count is below RhIg. Of those who do not maintain an
20,000 per microliter. A very low count increased platelet count and who
(<10,000) may result in the spontaneous require splenectomy, approximately 2/3
formation of hematomas in the mouth or have a sustained response and 10-15%
on other mucous membranes. Bleeding have a partial response.
time from minor lacerations or abrasions
is usually prolonged. Serious and In conclusion, bone marrow biopsy is
possibly fatal complications due to an essential in a patient with blood
extremely low count (<5,000) may dyscrasia because it helps identify the
include subarachnoid or intracerebral possible cause for proper management.
hemorrhage, lower gastrointestinal
bleeding, or other internal bleeding. An
ITP patient with an extremely low count REFERENCES:
is vulnerable to internal bleeding caused
by blunt abdominal trauma. For the Harrison’s Principle of Internal Medicine
pathogenesis, the cause is not 17th edition
idiopathic, but autoimmune, with
antibodies against platelets being
detected in approximately 60% of
patients. Most often, these antibodies
are against platelet membrane
glycoproteins IIb-IIIa or Ib-IX, and are
IgG type. The coating of platelets with
