Itp

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ITP

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Itp

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

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