ITYP

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:
a) Premature platelet destruction
c) Presence of splenomegaly
c) Immune mediated mechanism
d) Secondary causes excluded

4. #2 All of the following distinguish adult and
pediatric ITP, except:
a) Most pediatric ITP is acute (resolves within 4-6
weeks)
c) Most adult ITP is chronic (persists for years)
e) Both adult and pediatric ITP are common in
females
g) 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:
a) Systemic Lupus Erythematosus
c) Sickle cell disease
e) HIV infection
g) Acute viral hepatitis

6. #4 Following drugs could cause
thrombocytopenia, except
a) Cephalosporins
c) Heparin
e) Hydrochlorthiazide
g) Carbamezapine

7. #5 All are true about drug induced
thrombocytopenias except
a) Most drug induced thrombocytopenias would
recover in 7 to 10 days.
c) Upto 15% of individuals who receive heparin
develop thrombocytopenia
e) In case of heparin induced thrombocytopenia
(HIT), LMWH are a safe choice
g) If HIT occurs, it can cause worsening of
thrombosis

8. #6 ITP is a diagnosis of exclusion because:
a) The etiology of ITP is unknown
c) Most isolated thrombocytopenias are
secondary, and only a few remaining are ITP
e) Secondary causes are treatable hence these
must be diagnosed first
g) Good tests are not available to diagnose ITP

9. #7 All of the following are expected with ITP,
except
a) Peripheral thrombocytopenia
c) Reduced megakaryocytes in Bone marrow
e) Normocytic anemia
g) Absence of splenomegaly

10. #8 All of the following are risk factors for
spontaneous bleeding in ITP except
a) Presence of petechiae on skin
c) Past history of a major bleed
e) Age more than 60 years
g) Platelet count less than 10,000/micro-L

11. #9 Complete Blood count in ITP would
reveal
a) Mega-thrombocytes (High MPV)
c) Platelet anisocytosis (High PDW)
e) Microparticles (Broken platelets)
g) All of the above

12. #10 In management of adult ITP, the most
logical sequence of therapies is
a) Platelet transfusion, Antiglobulin, Steroids
c) Steroids, Splenectomy, anti-globulins
e) Splenectomy, steroids, repeat platelet
transfusion
g) Steroids, Antiglobulins, immunosuppresants,
splenectomy

13. #11 Use of steroids in ITP is associated with
all of the following except
a) Platelets rise by 1 week, peak levels by 2-4
weeks
c) In adults low dose and high dose had similar
response
e) If no response with a low dose by 4 weeks, a
high dose for 12 weeks should be given
g) 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
a) Reduced production of anti-platelet antibodies
c) Reduced destruction of Ab coated platelets
e) Reduced sequestration of platelets in spleen
g) Increased production of platelets in Bone
marrow

15. #13 All of the following indicate need for
splenectomy in ITP except
a) No response to steroids
c) Palpable spleen
e) Relapse during steroid tapering
g) Presence of a life threatening bleeding

16. #14 The following are expected post
splenectomy except
a) Rise in platelet counts within 48 hrs
c) Maximum platelet count expected in 7-10 days
e) Howell Jolly bodies appear in peripheral
circulation
g) Non-response suggests incomplete spleen
removal

17. #15 True about platelet transfusions in ITP
a) Are contraindicated
c) Are useful but do-not alter natural course
e) Are indicated if platelet counts <10,000
g) 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:
a) 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:
a) Acute Leukemias Bone Marrow
b) SLE ANA
c) HIV infection HIV serology
If ITP with Hepato-splenomegaly, Lymphadenopathy, or Atypical
lymphocytes consider:
g) Acute viral hepatitis
h) Toxoplasmosis
i) EBV infection
j) CMV infection
k) HIV

25. #4 Following drugs could cause
thrombocytopenia, except
• Cephalosporins
• Heparin
• Hydrochlorthiazide
• Carbamezapine

26. #4 Following drugs could cause
thrombocytopenia, except
a) Cephalosporins, Penicillin, Sulphonamide
c) Heparin (UFH)
e) Hydrochlorthiazide, rare ACE Inhibitors
g) 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:
a) ITP is due to presence of anti-platelet antibodies
directed against Gp IIb/IIIa
c) The tests for detection of these antibodies are
technically difficult, and may be positive in non-ITP
cases as well.
e) Normal platelets also release Immunoglobulin and it is
difficult to distinguish between endogenous and
exogenous antibodies
g) 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
a) Peripheral thrombocytopenia due to platelet
destruction
c) Normal megakaryocytes in Bone marrow –
Although abnormal platelets are produced
hyperplasia of megakaryocytes does not occur
e) Normocytic anemia – Due to blood loss
g) 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
a) Mega-thrombocytes (High MPV)
c) Platelet anisocytosis (High PDW)
e) Microparticles (Broken platelets)
g) 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
a) Steroids are conventional first line therapy
c) Failure to respond to steroids (by 6 weeks) is
indication for splenectomy
e) Failure to respond to both of above is known as
refractory ITP
g) 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
a) Platelets rise by 1 week, peak levels by 2-4
weeks
c) In adults low dose (0.25 mg/kg/d) and high
dose (1mg/kg/d) had similar response
e) If no response with a low dose by 4-6 weeks,
alternate modalities (splenectomy) to be
considered
g) 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
a) Reduced production of anti-platelet antibodies
(both in BM and in spleen)
c) Reduced destruction of Ab coated platelets
f) 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
a) No response (platelets <10,000) to steroids in
4-6 weeks
c) Relapse during steroid tapering
e) 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
a) Rise in platelet counts within 48 hrs
c) Maximum platelet count expected in 7-10 days
e) Howell Jolly bodies appear in peripheral
circulation
g) 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
a) Will transiently increase platelet count
c) Useful in management of serious life
threatening bleeding such as sub-arachnoid
hemorrhage
e) Used pre-operatively while planning
splenectomy