Thrombocytopenia differential diagnosis

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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 Mechanism Mechanism Inherited Acquried Clinical manifestations Para−clinical findings Gold standard Associated findings
Age range History Symptoms Signs
Lab Findings Imaging
Severity Fever Rash Bleeding BP Splenomegaly Jaundice Other CBC PBS Bone marrow exam PT PTT BT UA
Decreased platelet production Platelet destruction in bloodstream Platelet destruction in spleen/liver Plt HB WBC
Hematology Bone marrow disorders Myelodysplastic syndromes +
Aplastic anemia +
Acute leukemia +
Paroxysmal nocturnal hemoglobinuria (PNH) +
Thrombotic microangiopathy (TMA) Thrombotic thrombocytopenic purpura (TTP) +
Hemolytic uremic syndrome (HUS) +
DIC +
Congenital platelet disorders MYH-9 related disorders
Bernard-Soulier syndrome
Gray platelet syndrome
Wiskott-Aldrich syndrome
Thrombocytopenia with absent radius (TAR) syndrome
Alport syndrome
Von Willebrand disease
Nutrient deficiencies Folate, vitamin B12, copper +
Category Condition Mechanism Decreased platelet production Platelet destruction in bloodstream Platelet destruction in spleen/liver Inherited Acquried Age range History Severity Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT BT UA Imaging Gold standard Associated findings
Rheumatologic/autoimmune disorders Immune thrombocytopenia Antibody-mediated platelet destruction +
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
  • Direct toxicity to megakaryocytes
  • An ITP-like condition called primary HIV-associated thrombocytopenia (PHAT)
  • Secondary opportunistic infections
Other viruses such as rubella, mumps, varicella, parvovirus, hepatitis C, & Epstein-Barr virus +
Intracellular parasites Malaria
Babesiosis
Category Condition Mechanism Decreased platelet production Platelet destruction in bloodstream Platelet destruction in spleen/liver Inherited Acquried Age range History Severity Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT BT UA Imaging Gold standard Associated findings
Medication/toxicity Drug-induced immune thrombocytopenia
  • Antibiotics
    • Sulfonamides
    • Ampicillin
    • Piperacillin
    • Vancomycin
    • Rifampin
  • Older antiepileptic agents
    • carbamazepine
    • Phenytoin
  • Quinine
Occurrence of drug-dependent, platelet-reactive antibodies
Heparin-induced thrombocytopenia +
Cytotoxic chemotherapy +
Radiation therapy Predictable, dose-dependent myelosuppression +
OTC agents Quinine-containing beverages
GI Chronic liver disease +
Portal hypertension
Category Condition Mechanism Decreased platelet production Platelet destruction in bloodstream Platelet destruction in spleen/liver Inherited Acquried Age range History Severity Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT BT UA Imaging Gold standard Associated findings
Vascular Giant capillary hemangioma Platelet destruction +
Aortic aneurysm Platelet destruction +
Cardiopulmonary bypass Platelet destruction +
Other Alcohol +
Post-transfusion purpura Immune mediated platelet destruction +
Gestational thrombocytopenia

References