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ICD-9 : 287.31 • ICD-10 : D69.3   Image not available. Image not available. Image not available. Image not available.

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  • Thrombocytopenic purpura (TP) is characterized by cutaneous hemorrhages occurring in association with a reduced platelet count.
  • Hemorrhages are usually small (petechiae) but at times larger (ecchymoses).
  • Occur at sites of minor trauma/pressure (platelet count < 40,000/μL) or spontaneously (platelet count < 10,000/μL).

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Epidemiology

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Age of Onset

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Acute idiopathic thrombocytopenic purpura (ITP) mostly in children; drug-induced and autoimmune TP in adults.

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Sex

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Both sexes; HIV-associated TP—homosexual men > heterosexual females.

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Etiology and Pathogenesis

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Due to either decreased platelet production, splenic sequestration, or increased platelet destruction.

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  1. Decreased platelet production. Direct injury to bone marrow, drugs (cytosine arabinoside, daunorubicin, cyclophosphamide, busulfan, methotrexate, 6-mercaptopurine, vinca alkaloids, thiazide diuretics, ethanol, estrogens), replacement of bone marrow, aplastic anemia, vitamin deficiencies, Wiskott-Aldrich syndrome.

  2. Splenic sequestration. Splenomegaly, hypothermia.

  3. Increased platelet destruction. Immunologic: autoimmune TP, drug hypersensitivity (sulfonamides, quinine, quinidine, carbamazepine, digitoxin, methyldopa), after transfusion. Nonimmunologic: infection, prosthetic heart valves, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura.

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Platelet plugs by themselves effectively stop bleeding from capillaries and small blood vessels but are incapable of stopping hemorrhage from larger vessels. Platelet defects therefore produce problems with small-vessel hemostasis, small hemorrhages in the skin or in the CNS.

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Clinical Manifestation

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Usually sudden appearance of asymptomatic hemorrhagic skin and/or mucosal lesions.

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Skin Lesions

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Petechiae—small (pinpoint to pinhead), red, nonblanching macules that are not palpable and turn brown as they get older (Fig. 19-1); later acquiring a yellowish-green tinge. Ecchymoses—black-and-blue spots; larger area of hemorrhage. Vibices—linear hemorrhages (Fig. 19-1), due to trauma or pressure. Most common on legs and upper trunk, but may be anywhere.

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Figure 19-1
Graphic Jump Location

Thrombocytopenic purpura Multiple petechiae on the upper arm of an HIV-infected 25-year-old male were the presenting manifestation of his disease. The linear arrangement of petechiae at the site of minor trauma are called vibices.

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Mucous Membranes
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Petechiae—most often on palate (Fig. 19-2), gingival bleeding.

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Figure 19-2
Graphic Jump Location

Thrombocytopenic purpura Can first manifest on the oral mucosa or conjunctiva. Here multiple petechial hemorrhages are seen on the palate.

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General Examination
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Possible CNS hemorrhage, anemia.

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Laboratory Examinations

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Hematology

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Thrombocytopenia.

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Bone Marrow Aspiration

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Defines state of platelet production.

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Serology

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Rule out HIV disease.

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Lesional Skin Biopsy

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May be contraindicated due to postoperative hemorrhage; however, usually can be ...

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