This is an Undergraduate ITP and SLE Clinical case presentation by Pamudith Karunaratne

1. 28 April 2021
CLINICAL CASE
Haematology
Pamudith Karunaratne
Medical Undergraduate
Faculty of Medical Sciences
University of Sri Jayewardenepura

2. INTRODUCTION
Miss. xxxxxx xxxxxxx, a 16 year
old school girl from Dehiwala
presented to the haematology
clinic at CSTH for a routine
clinic visit.
2
INTRODUCTION

3. 5 years
back
Age 11
5 months
back
Age 16
Today
Apperently well
Purpuric
rash
B/L LL Oedema
3
From : Dehiwala
Occupation : Student
GENDER: Female
AGE: 16
PATIENT MEDICAL
HISTORY
Defaulted
Treatments

4. 5 years back
Age 11
4
PATIENT MEDICAL
HISTORY
Purpuric rash
● Black coloured patches
● Over the body, Upper & Lower limbs
● 2cm X 3cm Oval shaped
● After 1 Day turned inro RED
● Disappeared in next day
● Alternatively begins in another site
Haematology
clinic LRH
 ↓ PLT
 FBC

5. PATIENT MEDICAL
HISTORY
Purpuric rash
● Black coloured patches
● Over the body, Upper & Lower limbs
● 2cm X 3cm Oval shaped
● After 1 Day turned inro RED
● Disappeared in next day
● Alternatively begins in another site
5
Other than that, NO
● Other bleeding manifestations like gum bleeding, melena,
haematemesis, PV bleeding (Not attained menarche)
● Fever, Arthralgia, Myalgia, Retro-orbital pain suggestive of
viral fever
● LOA, LOW suggestive of haematological malignancy
● Butterfly rash, Alopecia, Arthritis, Renal/CNS involvement
suggestive of SLE
● history of blood transfusion
● Sepsis, trauma, Snake bite, prolonged bed ridden
suggestive of DIC
● Jaundice, ascites, haematemesis like features of liver
diseases that can lead to hypersplenism
● other drugs or medical conditions
5 years back
Age 11

6. PATIENT MEDICAL
HISTORY
Purpuric rash
● Black coloured patches
● Over the body, Upper & Lower limbs
● 2cm X 3cm Oval shaped
● After 1 Day turned inro RED
● Disappeared in next day
● Alternatively begins in another site
6
In the LRH,
● She was admitted
● Several blood investigations done
● ANA was negative
● Diagnosed to have ITP
● Treated with Oral Prednisolone 1mg/kg daily, then
reduced the dose over several weeks
After 1 month
● Prednisolone omitted and Dapsone 50mg bd & Folic acid
1mg is given.
● Frequency and the severity of the rash reduced
significantly
● These drugs taken for 2 years
● Then she developed an Urticarial rash so the clinic
decided it as allergy to Dapsone and omitted it.
● Then the clinic visits defaulted & not had relapses
5 years back
Age 11

7. PATIENT MEDICAL
HISTORY
Came to CSTH with relapse of the rash and some
symptoms of SLE
● BL / LL Swelling up to knee level
● Gum bleeding
● Achy joints and Difficulty in walking
● Fatigue
● Hair loss
SLE is suspected & referred to Rheumatology
Clinic,
● PLT 68,000
● ESR 85 CRP 8.5
● ANA Positive
● Anti ds-DNA positive
7
● 2D echo – normal with EF > 60%
● DRVVT - Dilute Russell's viper venom time - lupus anticoagulant weakly +
● Cervical Lymphadenopathy – LN Biopsy - Normal
● BM trephine Biopsy – suggestive of peripheral disorder of PLT
● Dental Referral done – Chlorhexidine Mouthwash &
Tranexamic acid mouthwash given
5 months back
Age 16
Symptoms

8. PATIENT MEDICAL
HISTORY PMHx – No Liver diseases, renal diseases, Thyroid
diseases
PSHx – Hx of blood transfusion, Splenectomy not
done
Allergies/Drugs – Mentioned above, Not on
anticoagulants or antiplatelets
Family Hx – No Family Hx of Haemophilia,
bleeding disorders, Renal & liver disease, SLE,
Haematological Malignancies
Social Hx – School girl at Grade 11
Have GCE OLs this year
Family support good
family income is adequate
Nearest hospital is CSTH 8

9. DIAGNOSIS
SUMMARY ∆ SLE + ITP
Current status of the patient,
Pt is Symptomatically better.
Compliance & clinic follow up is good.
Ix –
PLT 140,000
HGB 12.8
WBC 8.0
Rx
Azathioprine 50 mg mane
Hydroxychloroquine 200mg nocte
Prednisolone 5mg mane

10. • Corticosteroids
• IVIG
• IV anti-D
(component of
IVIG)
• Immunosuppress
10
Treatment options
For ITP
• Splenectomy
• H. pylori
eradication
ITP has no cure, and relapses may occur years after seemingly successful
medical or surgical management. Most children with acute ITP do not require
treatment, and the condition resolves spontaneously.

11. 11
Immune thrombocytopenia
(ITP) is a syndrome in which
platelets become coated with
autoantibodies to platelet
membrane antigens, resulting
in splenic sequestration and
phagocytosis by mononuclear
macrophages.
DISCUSSION
The resulting shortened life span
of platelets in the circulation,
together with incomplete
compensation by increased
platelet production by bone
marrow megakaryocytes, results
in a decreased number of
circulating platelets
Peripheral blood smear from a
patient with immune
thrombocytopenia (ITP) shows a
decreased number of platelets, a
normal-appearing neutrophil, and
normal-appearing erythrocytes.
ITP is diagnosed by excluding
other diseases

12. Impaired production
12
↑ Consumption Other
↑ Destruction
CAUSES
For Bleeding
 Leukaemia
 BM Failure
Aplastic Anaemia
Myelofibrosis
Multiple myeloma
Myelodysplasia
Tumour infiltration
 Megaloblastic Anaemia
 Cytotoxic drugs
 Radiation
 ITP
 2ry immune
SLE
Viral – HIV, Dengue
Drugs
 Post transfusion thrombocytopaenia
 DIC
 Thrombotic thrombocytopenic Purpura (TTP)
 Hypersplenism - Dilution
 Platelet functional disorder
 Massive transfusion - Dilution

13. 13
THANKS
Does anyone have any questions?
Pamudith@dr.com

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14
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