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Contributed by: Maureen Wyatt, ART, Kelowna General Hospital
Mr. H.M. is an 83 year-old male diagnosed with immune thrombocytopenic purpura (ITP).
On November 20 HM presented to his physician's office with nosebleeds. Subsequent investigations showed an underlying low grade lymphoproliferative disorder. His medical history includes ischemic heart disease, treated with medical therapy after occlusion of a bypass graft performed in 1971 and chronic obstructive pulmonary disease. He is considered a high surgical risk, therefore, splenectomy is not an option. At the time of admission he was treated with oral prednisone for the ITP. This was followed by two courses of high dose intravenous immunoglobulin (IVIG) therapy. He initially responded well but was unable to sustain the platelet increments.
In January vincristine was prescribed. While not recommended as a primary treatment it has been shown to be useful in ITP that is refractory to steroids and splenectomy. On January 4, the hematologist ordered Rh immune globulin (RhIG).
|Platelets||140 - 450 X 109/L|
|Creatinine||50 - 130 mmol/L|
|Haptoglobin||0.60 - 2.00 g/L|
|Total bilirubin||3 - 17 mmol/L|
HM was admitted to hospital for hematological workup following numerous uncontrolled nosebleeds.
Initial Laboratory Results (Nov. 20)
|Platelets||2 X 109/L|
The hematologist requested 0.4 gm IVIG /kg x 5 days. Patient weight was 81.9 kg. Patient was also started on prednisone.
Based on these results, red cells were electronically crossmatched and Mr. HM was transfused with one unit of RBC on November 20 and two RBC on each of 3 days (November 21-23) as he exhibited anemia-related symtoms. No adverse reactions were reported.
35 gm IVIG (Nov.20) and 30 gm IVIG (Nov. 21, 22, 23) were also transfused without incident.
Laboratory Results (Nov. 21-24)
|Nov. 21||86 g/L||3 X 109/L|
|Nov. 22||100 g/L||5 X 109/L|
|Nov. 23||122 g/L||13 X 109/L|
|Nov. 24||136 g/L||31 X 109/L|
Five platelet concentrates were requested by the on-call oncologist on Dec. 30. The patient was ABO and Rh retyped and the platelets were transfused as a pool without incident.
On Jan. 4, HM's hemoglobin was 129 g/L and his platelet count was 13 X 109/L. 4000 micrograms of RhIG were given in the ambulatory care unit.
Laboratory Results (Jan. 11)
|Platelets||73 X 109/L|
|Total bilirubin||12 mmol/L|
HM came to Emergency complaining of chest pain and was admitted to hospital.
Laboratory Results (Jan. 17)
|Platelets||34 X 109/L|
The patient's hemoglobin dropped 50g/L (129 g/L on Jan. 4 to 79 g/L on Jan. 17).
Two red cell concentrates were ordered.
Two group O Rh negative red cell concentrates were crossmatched (PEG-IAT) and transfused without incident on Jan. 17. The patient's chest pain had abated, his CBC showed a satisfactory increment, and he was discharged on Jan.18.
Laboratory Results (Jan. 18)
|Platelets||31 X 109/L|
|Total bilirubin||17 mmol/L|
On Jan. 25 two red cell concentrates were ordered. Two group O Rh positive RBC were crossmatched (PEG-IAT) and transfused without incident on Jan. 26 in the Ambulatory Care Unit. The patient's DAT was still positive but weaker (1+).
Laboratory Results (Jan. 25 - 26)
|Jan. 25||Jan. 26|
|Hemoglobin||91 g/L||113 g/L|
|Platelets||15 X 109/L||56 X 109/L|
After reviewing the case summary, consider these questions.
American Society of Hematology. Diagnosis and Treatment of Idiopathic Thrombocytopenic Purpura: Recommendations of the American Society of Hematology (Annals of Internal Medicine 1997;126:319-26.)
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