Emergency Medicine Case Challenge: Bleeding Gums and Rash on Both Legs in a 38-Year-Old Man

Basma Abdulhadi, MD


April 12, 2023

A diagnosis of ITP does not imply that therapy is required, especially in a patient with mild thrombocytopenia in the absence of clinical bleeding. The need for therapy is guided by bleeding symptoms and platelet counts. The goal of therapy in ITP patients is to minimize the risk for clinically significant bleeding by providing a safe platelet count. Clinically important bleeding is bleeding that requires medical attention, ranging from intracranial hemorrhage to nose bleeding.

ITP-specific therapy consists of high-dose glucocorticoids and intravenous immune globulin (IVIG). Glucocorticoids are considered first-line therapy for ITP. Patients whose platelets fail to respond to glucocorticoids can be given IVIG or rituximab. Of note, IVIG tends to raise platelet counts more rapidly than glucocorticoids and can be used in cases of severe active bleeding or if an urgent invasive procedure needs to be performed.

For patients with severe bleeding and platelet counts < 30,000/µL, platelet transfusions are given in addition to ITP-specific therapy. Patients with platelet counts < 20,000/µL, even without bleeding, may also benefit from ITP-specific therapies to bring platelet counts up to a safer level. Patients with platelet counts between 20,000/µL and 30,000/µL can mostly be managed with observation and close monitoring. Most patients with platelet counts > 30,000/µL can be safely observed with periodic CBC testing.[2,4,5] All patients should be educated to present to their clinicians if any signs of bleeding develop.[2,4,5]

The patient in this case had a platelet count of < 20,000/µL and bleeding from his oral blisters. He received platelet transfusions and glucocorticoids, with eventual resolution of his bleeding. He was safely discharged from the hospital after his platelet counts were > 40,000/µL. He was counseled about his diagnosis and the importance of seeking immediate medical attention if any symptoms of bleeding occurred. He was discharged with hematology outpatient follow-up and was scheduled for a repeat CBC in 1 week. Approximately 10% of adults with ITP achieve spontaneous remission within the first 6 months after diagnosis.[6] However, most require one or more therapies, and eventually reach a safe and stable platelet count.


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