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A 70-year-old woman is evaluated for a 4-month history of easy bruisability. Her medical history is otherwise noncontributory.
Physical examination, including vital signs, is normal. The complete blood count indicates a hemoglobin of 11.5 g/dL (115 g/L), leukocyte count of 4500/μL (4.5 × 109/L), and platelet count of 35,000/μL (35 × 109/L). Evidence of thrombocytopenia is noted on the peripheral blood smear. The patient is treated with prednisone, 1 mg/kg/d. After 3 weeks of therapy, the platelet count is 30,000/μL (30 × 109/L).
Which of the following is the most appropriate next step in management?
A Increase prednisone dose
B Add anti-Rh(D) immunoglobulin
C Perform bone marrow aspiration and biopsy
D Perform splenectomy
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C Perform bone marrow aspiration and biopsy
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there must be dramatic response to corticosteroids.
next step is spleenectomy
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DH how do you know this thing...... amazing....
Ans is C...
This patient has thrombocytopenia with mild anemia and therefore does not have truly isolated thrombocytopenia. Although often believed to be a disorder that primarily affects young women, recent population-based studies have demonstrated that the age-specific incidence of idiopathic thrombocytopenic purpura (ITP) may actually be highest in the elderly; therefore, ITP is a reasonable preliminary diagnosis in this patient. However, because approximately 80% of patients with ITP respond to the therapeutic regimen of prednisone given to this patient, almost always within 3 weeks, the initial diagnosis should be reconsidered, particularly in the setting of another hematologic abnormality, and bone marrow aspirate and biopsy should now be performed.
Occasionally, patients with ITP who do not respond to the standard initial dose of prednisone, 1 mg/kg/d, will respond to higher doses, particularly œpulses of intravenous corticosteroids (for example, intravenous methylprednisolone, 1 g). However, increasing the dose of prednisone is unlikely to make a significant difference in this patient's response to treatment. The use of other therapies, such as intravenous anti-RhD immunoglobulin or intravenous immunoglobulin G, might be considered in this patient, but they should not be used until the diagnosis of ITP is more strongly established.
Splenectomy would not be indicated in this patient until a diagnosis of ITP were confirmed. Moreover, even in patients with a classic response to ITP who ultimately become refractory to therapy, most experts recommend bone marrow examination before splenectomy.
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Thanks lymph for posting!
