Thrombocytopenia differential diagnosis: Difference between revisions

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| align="center" style="background:#F5F5F5;" + |History of alcohol use
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| align="center" style="background:#F5F5F5;" + |Cytopenia
| align="center" style="background:#F5F5F5;" + |Cytopenia
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Revision as of 03:37, 17 August 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farbod Zahedi Tajrishi, M.D.

Overview

Thrombocytopenia has a broad range of potential causes. While a good history and physical examination can be helpful to diagnose some of these causes such as drug-induced thrombocytopenia, they usually don't suffice and further evaluation is often needed. There are also some useful points that may guide the physician to an appropriate diagnosis. For example, asymptomatic, isolated thrombocytopenia most probably suggests ITP, while thrombocytopenia in critically ill, hospitalized patients is usually suggestive of iatrogenic causes (eg. dilution), platelet consumption, bone marrow suppression from infection/sepsis, or even drug-induced thrombocytopenia. One should consider however, that a wide variety of other conditions such as autoimmune disorders, nutrient deficiencies, thrombotic microangiopathies could all as well cause thrombocytopenia.

Thrombocytopenia Differential Diagnosis

Differentiating the diseases that can cause thrombocytopenia:

Category Condition Etiology Mechanism Inherited Acquried Clinical manifestations Para−clinical findings Gold standard Associated findings
Demography History Symptoms Signs
Lab Findings Imaging
Fever Rash Bleeding BP Splenomegaly Jaundice Other CBC PBS Bone marrow exam PT PTT UA
Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Plt HB WBC
Hematology Bone marrow disorders Myelodysplastic syndromes[1]
  • Unknown
  • Mutation
+ - - -/+ + Elderly Exposure to + Petechiae, purpura, diffuse erythematous rash + Nl + + Shortness of breath, fatigue Nl Nl Nl NA Bone marrow examination + clinical manifestation
Aplastic anemia +
Acute leukemia +
Paroxysmal nocturnal hemoglobinuria (PNH) +
Thrombotic microangiopathy (TMA) Thrombotic thrombocytopenic purpura (TTP) Deficiency of, or antibodies to, the metalloprotease ADAMTS13   + -/+ + Any age + Fragmented RBCs Nl Nl
Hemolytic uremic syndrome (HUS) + -/+ + Children Nl Nl
DIC + - + ↑↑
Congenital platelet disorders MYH-9 related disorders + - Large platelets
Bernard-Soulier syndrome Absence of

Gp Ib-IX-V  

+ -
Gray platelet syndrome + -
Wiskott-Aldrich syndrome Mutation in GATA-1   + -
Thrombocytopenia with absent radius (TAR) syndrome + -
Alport syndrome + -
Von Willebrand disease +
Nutrient deficiencies Folate, vitamin B12, copper +
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Imaging Gold standard Associated findings
Rheumatologic/autoimmune disorders ITP
  • Immune-mediated platelet destruction
  • Inhibition of platelet release from the megakaryocyte  
+ + - - + Any age - - Ecchymoses and

petechia

+ Mucocutaneous Nl - - - ↓↓↓ Nl Nl Nl Large platelets, otherwise normal Nl Nl Nl NA Diagnosis of exclusion Spontaneous remission  
Systemic lupus erythematosus (SLE) +
Antiphospholipid syndrome (APS) Autoantibody-mediated syndrome +
Felty's syndrome Splenomegaly +
Infection-induced Bacterial infections Sepsis Direct bone marrow suppression + +
Helicobacter pylori Immune thrombocytopenia +
Tick-borne infection +
Viral infections HIV An ITP-like condition called primary HIV-associated thrombocytopenia + + +
Other viruses such as rubella, mumps, varicella, parvovirus, hepatitis C, & Epstein-Barr virus +
Parasitic infections Malaria
Babesiosis
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Imaging Gold standard Associated findings
Medication/toxicity Antibiotics/

Antiepileptic

Occurrence of drug-dependent, platelet-reactive antibodies + +
Heparin-induced thrombocytopenia Anti-heparin/PF4 antibody  + ELISA Early or delayed-onset
Cytotoxic chemotherapy +
Radiation therapy Predictable, dose-dependent myelosuppression +
OTC agents Quinine-containing beverages
GI Chronic liver disease + + + ↓↓
Portal hypertension
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Imaging Gold standard Associated findings
Vascular Giant capillary hemangioma Platelet destruction +
Aortic aneurysm Platelet destruction +
Cardiopulmonary bypass Platelet destruction +
Other Alcohol + - + - + History of alcohol use - - - Nl + + Cytopenia Cytopenia Clinical manifestation
Post-transfusion purpura[2][3] Platelet destruction by anti-platelet antibodies - + - - + Women - Purpura, petechiae + - - - ↓↓↓ Nl Nl NA Nl Nl Nl NA Positive circulating alloantibody to a common platelet antigen
  • Severe but rare reaction
Gestational thrombocytopenia[4] Might be physiologic adaptation of pregnancy - - - - + Pregnant women
  • Positive history of mild thrombocytopenia
- - - Nl - - - Nl Nl Nl NA Nl Nl Nl NA Diagnosis of exclusion
  • Self-limited condition
HELLP syndrome[5][6] Unknown - + - - + Pregnant > 25 years - - + - + Nl NA Nl Nl Proteinuria NA Lab abnormalities

References

  1. Natelson, Ethan A.; Pyatt, David (2013). "Acquired Myelodysplasia or Myelodysplastic Syndrome: Clearing the Fog". Advances in Hematology. 2013: 1–11. doi:10.1155/2013/309637. ISSN 1687-9104.
  2. McCrae, Keith R.; Herman, Jay H. (1996). "Posttransfusion purpura: Two unusual cases and a literature review". American Journal of Hematology. 52 (3): 205–211. doi:10.1002/(SICI)1096-8652(199607)52:3<205::AID-AJH13>3.0.CO;2-E. ISSN 0361-8609.
  3. Pavenski, Katerina; Webert, Kathryn E.; Goldman, Mindy (2008). "Consequences of transfusion of platelet antibody: a case report and literature review". Transfusion. 48 (9): 1981–1989. doi:10.1111/j.1537-2995.2008.01796.x. ISSN 0041-1132.
  4. Reese, Jessica A.; Peck, Jennifer D.; Deschamps, David R.; McIntosh, Jennifer J.; Knudtson, Eric J.; Terrell, Deirdra R.; Vesely, Sara K.; George, James N. (2018). "Platelet Counts during Pregnancy". New England Journal of Medicine. 379 (1): 32–43. doi:10.1056/NEJMoa1802897. ISSN 0028-4793.
  5. Barnhart, Lynette (2015). "HELLP Syndrome and the Effects on the Neonate". Neonatal Network. 34 (5): 269–273. doi:10.1891/0730-0832.34.5.269. ISSN 0730-0832.
  6. Haram, Kjell; Svendsen, Einar; Abildgaard, Ulrich (2009). "The HELLP syndrome: Clinical issues and management. A Review". BMC Pregnancy and Childbirth. 9 (1). doi:10.1186/1471-2393-9-8. ISSN 1471-2393.