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ITP

ITP

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Itp Presentation Transcript

  • 1. Idiopathic thrombocytopenic purpura
  • 2. MCQs follow
    • Please indicate your responses on the paper as the questions appear
    • There are 15 questions, each with four options and with one correct response
    • We will move to next question when all are done
  • 3. #1 All of the following are components in the definition of ITP except:
    • Premature platelet destruction
    • Presence of splenomegaly
    • c) Immune mediated mechanism
    • d) Secondary causes excluded
  • 4. #2 All of the following distinguish adult and pediatric ITP, except:
    • Most pediatric ITP is acute (resolves within 4-6 weeks)
    • Most adult ITP is chronic (persists for years)
    • Both adult and pediatric ITP are common in females
    • Most adult ITP is autoimmune due to Gp IIb/IIIa antibodies, while pediatric ITP is due to antibodies which mimic viral antigens
  • 5. #3 All of the following are differential diagnosis of adult ITP except:
    • Systemic Lupus Erythematosus
    • Sickle cell disease
    • HIV infection
    • Acute viral hepatitis
  • 6. #4 Following drugs could cause thrombocytopenia, except
    • Cephalosporins
    • Heparin
    • Hydrochlorthiazide
    • Carbamezapine
  • 7. #5 All are true about drug induced thrombocytopenias except
    • Most drug induced thrombocytopenias would recover in 7 to 10 days.
    • Upto 15% of individuals who receive heparin develop thrombocytopenia
    • In case of heparin induced thrombocytopenia (HIT), LMWH are a safe choice
    • If HIT occurs, it can cause worsening of thrombosis
  • 8. #6 ITP is a diagnosis of exclusion because:
    • The etiology of ITP is unknown
    • Most isolated thrombocytopenias are secondary, and only a few remaining are ITP
    • Secondary causes are treatable hence these must be diagnosed first
    • Good tests are not available to diagnose ITP
  • 9. #7 All of the following are expected with ITP, except
    • Peripheral thrombocytopenia
    • Reduced megakaryocytes in Bone marrow
    • Normocytic anemia
    • Absence of splenomegaly
  • 10. #8 All of the following are risk factors for spontaneous bleeding in ITP except
    • Presence of petechiae on skin
    • Past history of a major bleed
    • Age more than 60 years
    • Platelet count less than 10,000/micro-L
  • 11. #9 Complete Blood count in ITP would reveal
    • Mega-thrombocytes (High MPV)
    • Platelet anisocytosis (High PDW)
    • Microparticles (Broken platelets)
    • All of the above
  • 12. #10 In management of adult ITP, the most logical sequence of therapies is
    • Platelet transfusion, Antiglobulin, Steroids
    • Steroids, Splenectomy, anti-globulins
    • Splenectomy, steroids, repeat platelet transfusion
    • Steroids, Antiglobulins, immunosuppresants, splenectomy
  • 13. #11 Use of steroids in ITP is associated with all of the following except
    • Platelets rise by 1 week, peak levels by 2-4 weeks
    • In adults low dose and high dose had similar response
    • If no response with a low dose by 4 weeks, a high dose for 12 weeks should be given
    • No pre-treatment characteristics have predicted which patients are likely to respond
  • 14. #12 Benefit due to steroids is due to all of the following mechanisms except
    • Reduced production of anti-platelet antibodies
    • Reduced destruction of Ab coated platelets
    • Reduced sequestration of platelets in spleen
    • Increased production of platelets in Bone marrow
  • 15. #13 All of the following indicate need for splenectomy in ITP except
    • No response to steroids
    • Palpable spleen
    • Relapse during steroid tapering
    • Presence of a life threatening bleeding
  • 16. #14 The following are expected post splenectomy except
    • Rise in platelet counts within 48 hrs
    • Maximum platelet count expected in 7-10 days
    • Howell Jolly bodies appear in peripheral circulation
    • Non-response suggests incomplete spleen removal
  • 17. #15 True about platelet transfusions in ITP
    • Are contraindicated
    • Are useful but do-not alter natural course
    • Are indicated if platelet counts <10,000
    • Should be given to prevent a major bleed
  • 18. Correct Responses
    • Mark yourself
    • Honestly ………..
  • 19. #1 All of the following are components in the definition of ITP except:
    • Premature platelet destruction
    • Presence of splenomegaly
    • c) Immune mediated mechanism
    • d) Secondary causes excluded
  • 20. #1 All of the following are components in the definition of ITP except:
    • Premature platelet destruction
    • c) Immune mediated mechanism
    • d) Secondary causes excluded
    • Typically splenomegaly is absent
  • 21. #2 All of the following distinguish adult and pediatric ITP, except:
    • Most pediatric ITP is acute (resolves within 4-6 weeks)
    • Most adult ITP is chronic (persists for years)
    • Both adult and pediatric ITP are common in females
    • Most adult ITP is autoimmune due to Gp IIb/IIIa antibodies, while pediatric ITP is due to antibodies which mimic viral antigens
  • 22. #2 All of the following distinguish adult and pediatric ITP, except:
    • Most pediatric ITP is acute (resolves within 4-6 weeks)
    • Most adult ITP is chronic (persists for years)
    • Pediatric ITP has no sex prediliction, adult ITP is common in females
    • Most adult ITP is autoimmune due to Gp IIb/IIIa antibodies, while pediatric ITP is due to antibodies which mimic viral antigens
  • 23. #3 All of the following are differential diagnosis of adult ITP except:
    • Systemic Lupus Erythematosus
    • Sickle cell disease
    • HIV infection
    • Acute viral hepatitis
  • 24. #3 All of the following are differential diagnosis of adult ITP except:
    • Acute Leukemias Bone Marrow
    • SLE ANA
    • HIV infection HIV serology
    • If ITP with Hepato-splenomegaly, Lymphadenopathy, or Atypical lymphocytes consider:
    • Acute viral hepatitis
    • Toxoplasmosis
    • EBV infection
    • CMV infection
    • HIV
  • 25. #4 Following drugs could cause thrombocytopenia, except
    • Cephalosporins
    • Heparin
    • Hydrochlorthiazide
    • Carbamezapine
  • 26. #4 Following drugs could cause thrombocytopenia, except
    • Cephalosporins, Penicillin, Sulphonamide
    • Heparin (UFH)
    • Hydrochlorthiazide, rare ACE Inhibitors
    • Chemotherapeutic agents – carboplatin, alkylating agents, anti-metabolites
  • 27. #5 All are true about drug induced thrombocytopenias except
    • Most drug induced thrombocytopenias would recover in 7 to 10 days.
    • Upto 15% of individuals who receive heparin develop thrombocytopenia
    • In case of heparin induced thrombocytopenia (HIT), LMWH are a safe choice
    • If HIT occurs, it can cause worsening of thrombosis
  • 28. #5 All are true about drug induced thrombocytopenias except
    • Most drug induced thrombocytopenias would recover in 7 to 10 days.
    • Upto 15% of individuals who receive heparin develop thrombocytopenia
    • 80 to 90% of antibodies generated against heparin, cross react against LMWH as well.
    • If HIT occurs, it can paradoxically cause worsening of thrombosis due to development of DIC
  • 29. #6 ITP is a diagnosis of exclusion because:
    • The etiology of ITP is unknown
    • Most isolated thrombocytopenias are secondary, and only a few remaining are ITP
    • Secondary causes are treatable hence these must be diagnosed first
    • Good tests are not available to diagnose ITP
  • 30. #6 ITP is a diagnosis of exclusion because:
    • ITP is due to presence of anti-platelet antibodies directed against Gp IIb/IIIa
    • The tests for detection of these antibodies are technically difficult, and may be positive in non-ITP cases as well.
    • Normal platelets also release Immunoglobulin and it is difficult to distinguish between endogenous and exogenous antibodies
    • Newer assays to detect anti-platelet antibodies are under development, till that time ITP remains a diagnosis of exclusion
  • 31. #7 All of the following are expected with ITP, except
    • Peripheral thrombocytopenia
    • Reduced megakaryocytes in Bone marrow
    • Normocytic anemia
    • Absence of splenomegaly
  • 32. #7 All of the following are expected with ITP, except
    • Peripheral thrombocytopenia due to platelet destruction
    • Normal megakaryocytes in Bone marrow – Although abnormal platelets are produced hyperplasia of megakaryocytes does not occur
    • Normocytic anemia – Due to blood loss
    • Absence of splenomegaly
  • 33. #8 All of the following are risk factors for spontaneous bleeding in ITP except
    • Presence of petechiae on skin
    • Past history of a major bleed
    • Age more than 60 years
    • Platelet count less than 10,000/micro-L
  • 34. #8 All of the following are risk factors for spontaneous bleeding in ITP except
    • Past history of a major bleed
    • Age more than 60 years
    • Platelet count less than 10,000/micro-L
    • Any associated coagulopathy
    • Relation of bleeding to platelet count
    • <10,000 Severe spontaneous bleeding
    • 10,000 to 50,000 Significant bleeding (Ecchymosis / Petechiae)
    • >50,000 Bleeding after trauma / surgery
  • 35. #9 Complete Blood count in ITP would reveal
    • Mega-thrombocytes (High MPV)
    • Platelet anisocytosis (High PDW)
    • Microparticles (Broken platelets)
    • All of the above
  • 36. #9 Complete Blood count in ITP would reveal
    • Mega-thrombocytes (High MPV)
    • Platelet anisocytosis (High PDW)
    • Microparticles (Broken platelets)
    • Lower the platelet count, higher MPV which is paradoxical to other conditions associated with Thrombocytopenia such as sepsis / DIC where MPV is low
  • 37. #10 In management of adult ITP, the most logical sequence of therapies is
    • Platelet transfusion, Antiglobulin, Steroids
    • Steroids, Splenectomy, anti-globulins
    • Splenectomy, steroids, repeat platelet transfusion
    • Steroids, Antiglobulins, immunosuppresants, splenectomy
  • 38. #10 In management of adult ITP, the most logical sequence of therapies is
    • Steroids are conventional first line therapy
    • Failure to respond to steroids (by 6 weeks) is indication for splenectomy
    • Failure to respond to both of above is known as refractory ITP
    • Immunoglobulins / immunosuppresants have been tried in refractory ITP
  • 39. #11 Use of steroids in ITP is associated with all of the following except
    • Platelets rise by 1 week, peak levels by 2-4 weeks
    • In adults low dose and high dose had similar response
    • If no response with a low dose by 4 weeks, a high dose for 12 weeks should be given
    • No pre-treatment characteristics have predicted which patients are likely to respond
  • 40. #11 Use of steroids in ITP is associated with all of the following except
    • Platelets rise by 1 week, peak levels by 2-4 weeks
    • In adults low dose (0.25 mg/kg/d) and high dose (1mg/kg/d) had similar response
    • If no response with a low dose by 4-6 weeks, alternate modalities (splenectomy) to be considered
    • No pre-treatment characteristics have predicted which patients are likely to respond
  • 41. #12 Benefit due to steroids is due to all of the following mechanisms except
    • Reduced production of anti-platelet antibodies
    • Reduced destruction of Ab coated platelets
    • Reduced sequestration of platelets in spleen
    • Increased production of platelets in Bone marrow
  • 42. #12 Benefit due to steroids is due to all of the following mechanisms except
    • Reduced production of anti-platelet antibodies (both in BM and in spleen)
    • Reduced destruction of Ab coated platelets
    • Increased production of platelets in Bone marrow
  • 43. #13 All of the following indicate need for splenectomy in ITP except
    • No response to steroids
    • Palpable spleen
    • Relapse during steroid tapering
    • Presence of a life threatening bleeding
  • 44. #13 All of the following indicate need for splenectomy in ITP except
    • No response (platelets <10,000) to steroids in 4-6 weeks
    • Relapse during steroid tapering
    • Low platelets (<30,000) for more than 3 months despite steroid therapy
  • 45. #14 The following are expected post splenectomy except
    • Rise in platelet counts within 48 hrs
    • Maximum platelet count expected in 7-10 days
    • Howell Jolly bodies appear in peripheral circulation
    • Non-response suggests incomplete spleen removal
  • 46. #14 The following are expected post splenectomy except
    • Rise in platelet counts within 48 hrs
    • Maximum platelet count expected in 7-10 days
    • Howell Jolly bodies appear in peripheral circulation
    • Non-response suggests presence of accesory spleens (50% of non-responders may have them). Which calls for Technicium / Indium scans, followed by accessory splenectomy
  • 47. #15 True about platelet transfusions in ITP
    • Are contraindicated
    • Are useful but do-not alter natural course
    • Are indicated if platelet counts <10,000
    • Should be given to prevent a major bleed
  • 48. #15 True about platelet transfusions in ITP
    • Will transiently increase platelet count
    • Useful in management of serious life threatening bleeding such as sub-arachnoid hemorrhage
    • Used pre-operatively while planning splenectomy