Case based discussion!

1. THROMBOCYTOPENIA CASE BASED
DISCUSSION
• Dr Nilesh Wasekar MD MED DM HEMAT BMT Fellowship
• Centre For Blood Cancer

2. PLATELET
• Difficult Job

3. COMPETITOR
•PAPAYA LEAVES…………
•STEROIDS……..
•Google

4. •HISTORY

5. •25 years old man
•H/o fever 10 days back
•Received some treatment for fever at
hospital
•Platelet count dropped on day 15 of
admission

6. •HB 11.0
•Retic 1
•Platelet 25000
•PS Large platelets+
•LDH 400
•DCT negative

7. •Piperacillin Tazobactum
•Drug stopped and he
improved dramatically

8. DRUG INDUCED THROMBOCYTOPENIA

9. •90% of thrombocytopenias
can be concluded with the
help of good history

10. CURIOUS CASE OF
THROMBOCYTOPENIA

11. •35 years old female
•Cbc done for
Ghabarahat
•Pl count 20000

12. CHAPTER-1
•PANIC

13. •Platelet count in
CITRATE/HEPARIN
•Platelet dropped to
15000

14. CHAPTER-2
•PANIC

15. PBS

16. PBS
•Panpseudothrombocytope
nia

17. SMART PHYSICIAN

18. •25yr/female, PNC day 3
•presented with easy fatigability, fever,
headache, nausea, jaundice, cola coloured
urine
•CBC picture: Hb 7.3 Plt 20000
•PT/APTT Normal LDH 7000
•Billirubin 5 (I: 4) Retic 25 Creatinine 0.9
•Haptoglobin low
•Plasmic score: 7 {High RISK}
18

19. • PS was having :

20. •MAHA/TTP
•ADAMTS 13 was low
•Responded well to TPX

21. LEUCOCYTOSIS WITH
THROMBOCYTOPENIA WHEN IT IS NOT A
LEUKEMIA OR LEUKEMOID REACTION

22. HISTORY
• 42 years old female presented
with fever from 3 days!
• CBC was done Hb 12 TLC
35000 [N 79 L 19 M 2] Platelet
1,29,000
• Dengue Ns1ag positive
• Had stormy course,
Hypotension recovered

23. • Day 7
• Fever persistent
• Leucocytosis persistent ----neutrophilic
predominance
• Borderline thrombocytopenia persistent
• ? Secondary bacterial infection
• Blood culture Normal
• Ferritin 2500 LDH 750

24. • Line removed -----tip staph aureus ----sensitive to
Teicoplanin
• Fever persistent
• Sepsis Panel done -----Enetrobacteria/OXA-48
• Started on Zavicefta+Aztreonam
• Caspofungin empirically added
• Fever persistent platelet dropped to 80000
• Did BMA BMBX

25. BMA BMBX
EBER

26. VIRAL PANEL

28. DOUBLE WHAMMY

29. CASE
• A 16-years/girl,
• Fever, Rash, Headache
• Thrombocytopenia
• ? Viral Fever----
• DENGUE NS1AG----PCR Negative

30. INVESTIGATIONS
• Platelet count of 20k, haemoglobin concentration of 8.9
g/L
• RFT normal
• Liver enzymes borderline
• Billirubin 1.5 Direct 1
• PT 25 APTT 38

31. MRI BRAIN
•CVST

32. DD
• DIC
• Thrombotic thrombocytopenic purpura
• COVID-19 related thrombotic microangiopathy
• PNH
• APLA

33. PROBLEMS
•How to treat it
•How to anticoagulate with such
low platelet

34. HOW DID WE MANAGE HER
IVIG 400 mg
/kg/day 5 days
MPS 250 OD for 3
days
Platelet improved
to 35 on day 2
Started on LMWH
1mg/kg OD then
BD PC 80k
Day 4 PC 1.6 added
warfarin
Eltrombopag PC
dropped as steroids
were tapered

35. AT PRESENT
•Tab warf 1.5 mg daily -------planned for 3
months!
•Eltrombopag 25 mg OD
•Her platelet count is 1.5 lakh
•INR is 2-3

36. 30 years old male
presented with right
hypochondriac pain and
swelling.
No h/o fever
No h/o weight loss
No h/o passage of dark
colour stool

37. CBC normal Platelet Count 90k
Ldh 3500
Uric acid 13

38. •CT abdomen was suggestive of mass
of size 4#3#4 cm in right
hypochondriac region
•Biopsy done BMA 40% blast
•

39. CD 20 AND MIB[KI67]

40. C-MYC BY FISH

41. BURKITTS LYMPHOMA

42. UNCOMMON
PRESENTATION OF A
COMMON DISEASE

43. • 12 years old boy
• Anemia
• CBC picture: Hb 5 Platelet 35000
• Billirubin 5.0 (I)
• Retic 1
• LDH 5000
• PS: Macro, macroovalo, Sperocytes, BS, Schistiocytes

44. 44
B12 levels : 45
B12 deficiency anemia

45. SEVERE B12 DEFICIENCY PRESENTING AS
HEMOLYTIC ANEMIA

46. HEMATOLOGIST’S BREAD AND BUTTER

47. 1ST ADMISSION
• 20 years old girl presented
at emergency with
• Petechiae / ecchymosis and
Hematurea
• Physical examination
• Extensive petechiae /
ecchymosis
• Subconjuctival bleed
• CBC shows
• Hb 12.9 gm/dl
• TLC 8200
• P64 L30 M3 E3
• Platelet 8,000
• No other significant
history

48. INVESTIGATIONS
• PS – Normal
• TSH – Normal
• HIV
• HbsAg
• Anti HCV
Negative

49. IMMUNE THROMBOCYTOPENIA
• Mandatory investigations
• CBC PBS HHH TFT
• Don’t do
• ANA
• Anti platelet antibodies

50. BONE MARROW
STUDIES
Role of BMA/BMBX
• Not indicated
Pancytopenia
Abnormal cells on PBS
Hepatosplenomegaly/lymphadenopathy

51. DENGUE RELATED TCP

52. CASE 1
• 22 years old college student, symptomatic for fever 1
week back,
• Thrombocytopenia 35000
• Dengue Ns1ag/IgM +,
• PT APTT normal
• IPF: 12
• Advised discharge and follow up after 5 days with
platelet count

54. IPF
• Increased consumption/destruction
- High IPF
• Decreased production (marrow
failure) – Low IPF
• It predicts the timing of platelet
recovery
• It can save platelet transfusions

55. HOW TO
MANAGE ACTIVE
BLEEDING
Platelet transfusion if actively bleeding or PC less than
10000
Tranexamic acid(Except in Urinary tract bleeding)
Check PT APTT fibrinogen if LFT is deranged to correct the
coagulopathy with
FFP 10ml/kg (if PT APTT is prolonged and active bleeding is
present)
Cryoprecipitate 1 bag/10kg if fibrinogen is less than 150

56. PLATELET TRANSFUSION
If life threatening
bleeding
Patient is planned
for surgery

57. SDP VS
RDP
• Cost
• Availability
• SDP= 40k
• RDP=5k
• Exposure to multiple donor
antigens : alloimmunization,
Allergic Reactions, TTD

58. ROLE OF
STEROIDS
• Steroids are not indicated in dengue---CDC
• Delayed platelet recovery----behaving like ITP
• Platelet count less than 30000, Pancytopenia,
ferritin above 10000, features of HLH
• Platelet refractoriness
• Short course of steroids can be given { Dexa 4-8
mg BID for 2-4 days; MPS 125 mg OD for 2-3
days} provided sepsis/secondary infection is ruled
out

59. FERRITIN
• Not all high ferritin = HLH!
Schram and colleagues
(2015) reported on 113
pts with ferritin > 50,000
and only 17% had HLH

60. ROLE OF
PAPAYA
There is no RCT to prove the role
Capraine alkaloid helps in increasing the PC
Harm----We don’t know
Standardisation? dose ?
There is a scope for research

61. THANK YOU
9766185562