DIAGNOSTIC APPROACH OF THROMBOCYTOPENIA

Anna Mira LubisHematology and Medical Oncology Division

Department of Internal Medicine

Universitas Indonesia- Cipto Mangunkusumo Hospital

Disclosure

• Nothing to disclose

Outline

• Thrombopoiesis

• Platelet life span

• Lab. test for thrombocytopenia

• Diagnosis algorithm of thrombocytopenia

• Cases of thrombocytopenia

• Summary

Hematopoiesis

THROMBOPOIESIS (Megakaryocyte development)

Alan D.Michelson.Platelets.3rd ed.2013

THROMBOPOIESIS (platelet production)

Alan D.Michelson.Platelets.3rd ed.2013

Platelet life span

• Human body produces approximately 100 billion platelets/day

• Majority are cleared by RES in the liver and spleen

• Time in circulation is up to 10 days

• Genetic or pharmacological manipulation of the apoptotic program, can reduce or extend platelet life span in vivo

• Multiple-hit model (the rate at which plt endure hits; the number of hits a plt can withstand) platelet survival platelet life span

Definition

• Platelet count < the lower limit of normal value ( 150 x 109/L).

• Mild (100.000-150,000/microL), moderate (50,000 – 99,000/microL) and severe (< 50,000/microL)

• Associated with an increased risk of mortality in critically ill patients.

• As a marker of organ impairment and as a poor prognosis

Roberto S. ASH education book.2012

Mechanism of thrombocytopenia

thrombocytophenia

Megakaryocyte development ⇩

Platelet production ⇩

Platelet survival ⇩

Less common mechanisms are platelet sequestration ( redistribution of platelet from circulating pool to splenic pool) and hemodilution

Roberto S. ASH education book.2012

Diagnostic approach

History taking and physical examination :- Family history

- Temporal profile

- Disease history (autoimmune, infection, malignancy)

- Pregnancy

- Recent medications and vaccinations

- Recent travels

- Recent transfusion

- Recent organ transplantation

- Alcohol and quinine-containing drugs

- Risk factors for retroviral/hepatitis infection

- Location and bleeding severity

- Organomegaly

- Sceletal abnormalities

Laboratory Test • Peripheral blood smear (blood lineage)

• Liver and renal function

• Hemostasis

• LDH

• BM aspiration and biopsy

• Reticulated platelet / immature platelet fraction/MPV

• Plasma glycocalicin

• Thrombopoietin level

Common causes of thrombocytopenia

Roberto S. ASH education book.2012

Mechanism of drug induced thrombocytopenia

How I evaluate and treat thrombocytopenia in the intensive care unit patient.Blood.2016

Major mechanism of thrombocytopenia in ICU

pseudothrombocytopenia

Hemodilution Platelet consumption

Platelet sequestration

Decreased platelet production

Platelet destruction

Platelet aggregates in EDTA-anticoagulated blood

Infusion of fluids/plasma

- Blood loss- Massive

trauma- DIC- Sepsis- Extracorporeal

circuit

hepatosplenomegaly

- Intoxication- Viral infection- BM infiltration- Radiation- chemotherapy

- Immune thrombocytopenia

- DITP- TTP-HUS- PTP- Passive

alloiimunethrombocytopenia

How I evaluate and treat thrombocytopenia in the intensive care unit patient.Blood.2016

Clues for diagnosis of thrombocytopenia in critically-ill patients

Jacko Thachill. How do we approach thrombocytopenia in critically ill patients? British Journal oh Haematology.2016

Novel test Mean Platelet Volume ( MPV )

Immature Platelet Fraction ( IPF )

Plasma glycocalicin Monoclonal Antibody-Specific of Immobilization Platelet Antigens (MAIPA)

TrombopoietinLevel

- Discriminate over destruction >< under production

- Peripheral destructionBM production immature platelet MPV is higher

- Cut-off : 8,8 fL- Sen/spe

77%/89%

- Newl platelet contain NRA

- RNA –staining fluorescent dyes

- Discriminate over destruction >< under/recovery production

- Acute and chronic

- Active disease, th/ response and disease relapse

- Extracellulartdomain of platelet Glycoprotein Ib Ɑ platelet destruction

- Sera containing platelet-reactive Abs (auto and alloAb) against major pltmembrane constituents (glycoproteins and HLA class 1)

- Diagnostic tools immune mediated platelet destruction

- Key regulator of megakaryocyte development and platelet production production

- Treatment

Lalita, et al. The use of mean platelet volume for distinguishing the causes of thrombocytopenia in adults patients. Hematology reports.2019Alan D.Michelson.Platelets.3rd ed.2013

Diagnostic algorithm

Roberto S. ASH education book.2012

Case 1

• Tn. PH, 44 thn , 16/10/1973, 23/8/2018

• Keluhan hematuria sejak 1 minnggu SMRS.

• Hematuria sejak 2013,hilang timbul. Berulang kembali di 2015 dan 2017, terakhir 1 minggu yang lalu. Riwayat trombositopenia sejak 2013, denganhematuria beberapa kali,bercampur klot darah, hilang timbul, tidak nyeri. Perdarahan ditempat lain tidak ada. Nyeri perut -, demam -, komorbid -. Konsumsi obat-obatan ketosteril. Riwayat transfusi -, nyeri sendi-.

• Dikonsulkan karena trombositopenia pro tindakan sistoskopi danpemasangan DJ Stent.

• Pemeriksaan fisik : dalam batas normal

• 28/6/2013 : Hb 14,5, Ht 40, Leu 6550,Tr 45.000, UL : darah +3, eritrosit penuh

• 20/3/2015 : Hb 15,8, leu 6030, Tr 61.000

• 10/4/2015 : Hb 15, leu 6950 (0/2/1/56/34/7), Tr 77.000, ANA IF 1/100

• 20/8/2019 : Hb 15,1, Ht 42, leu 11.820 (0/1/0/64/28/7), tr 87.000, urcr 26/0,8, PSA 0,74

• CT urografi : HN dan HU kanan sampai distal, VU dinding menebal, additional shadow di dinding posterolateral kanan buli, lesi idodenskecil yang sebagian menempel dengan dinding buli sisi kiri bag. Posterior, curiga bekuan darah DD/massa

• Masalah :

1. Isolated trombositopenia

2. Hematuria (ca buli? ) pro sistoskopi dan pemasangan DJ stent kanan

DPL, GDT, IPF, SGOT/SGPT, Alb/glob, elektroforesa protein, imunofiksasi HBsAg, Anti HCV, Anti HIV, TSHs, FT4, PT/APTT

• Hb 14,4, Ht 41, Leu 14200 (0/1/0/78/12/9), Tr 150.000, IPF 3,9, GDT : neutrofilia danmonositosis, trombosist morfologinormal

• Alb/glob 4,8/3,3• SGOT/PT 20/18• Ur/cr 37/1• HBs Ag NR• Anti HCV NR• Anti HIV reaktif• FT4/TSHs 0,56/11,65

• SPEP : peningkatan fraksi alfa1 danbeta2 globulin, peningkatan fraksigamma globulin dengan gambaranpoliklonal

• Imfix : tidak tampak gamopatimonoclonal

• CD4 %/abs : 13/223• HIV RNA Konvensional : 1,23x104,

(SI 2,05 x 104 )• IGRA +

• Hasil Histopatologi buli (25/8/18) : sediaan terdiri atas jaringan ototdan jaringan ikat longgar, dengan sebukan ringan sampai sedang selradang menahun dan PMN. Setempat-setempat tampak proliferasi selhistiosit/makrofag disertai sel datia jenis langhans --> sesuai denganradang granulomatosa, kemungkinan ec tuberculosis

Case 2

• NY. MM, NMR 439-69-93, 27/7/1949

• MRS 1/8/2019

• Keluhan sulit komunikasi sejak 2 bulan yl, bicara melantur dan seringlupa. 2 mg terakhir tangan dan tungkai kanan lemah. Dari MRI brain, dikatakan terdapat tumor di basal ganglia kiri, dan direncanakan utkradiasi. Komorbiditas -

• Selama pengobatan riw kejang 1x, dan saat ini dalam WBRT

• Terapi : dexametason, ondansentron, omeprazole, depakene (3/8) loading 3x500 mg, ceftriaxone

• Tgl 2/9/2019 : pasien dikonsulkan karena trombositopenia

• 2/8/2019 :

• Hb 12,6, Ht 36, leuko 21270 (0,1/0,5/78,5/14,3/6,6/0), tr 313.000

• SGOT/PT : 13/35, Cr 0,5

Drug induced thrombocytopenia?

DPL, IPF, GDT, LDH, stop asam valproate

6/8 11/8 17/8 22/8 24/8 28/8 30/8 31/8 2/9 3/9 5/9 6/9 8/9 10/9 16/9 26/9

Hb 14,7 12,3 10,3 10,6 10,4 10,5 10,3 11,8 11,5 11,2 10 9,8 10,3 9,6 10,3 12

Ht 41,6 36,1 29 28,6 28,9 30,1 28,4 32,8 32,3 30,9 27,8 27,6 28,6 25,9 28,3 32,5

Leu 21320 23330

23890

17680

14190

7370 7920 12140

11380

11610

11030

14290

15390

15450

10430

8140

TR 275.000

235.000

264.000

206.000

159.000

79.000

70.000

65.000

79.000

97.000

92.000

100.000

147.000

154.000

172.000

180.000

IPF 1,5

GDT

Drug exposure

Drug withdrawal

Plt recovery

0

50000

100000

150000

200000

250000

300000

3-Aug 13-Aug 23-Aug 2-Sep 12-Sep 22-Sep 2-Oct

Platelet count

Trombosit

val acid withdrawal

Case 3

• Tn. NE, 433-83-85, 5/5/1957

• Kunjungan I : 5/12/2018

• Keluhan tidak enak badan sejak 2 mg SMRS, riwayat demam, batukdan cenderung tidur/lemas, penurunan BB +, demam lama -, kedaerah malaria-

• Komorbid DM : th/ diamicron 1x60 tab dan metformin 3x500 mg

Pemeriksaan Fisik

• TV normal

• Splenomegali S1

• Extremitas udem+/+

Pemeriksaan penunjang

• 19/11/2018 : Hb 12,4, Leuko 8700, Trombosit 135.000

• 5/12/2018 : Hb 9,8, Leuko 4080 (0/3/0/78/17/2), Tr 32.000, IPF 10.1%, retikulosit 0,75%

• GDT : pansitopenia, blast -

• HBsAg/Anti HCV/Anti HIV -/-/-

• Alb/glob 2,7/2,6

• LDH 2553

• As urat 6,3

• IgM/IgG dengue -/-

1. Pansitopenia dengan splenomegaly BM problem : leukemia, limfoma, MDS?

2. DM II

Aspirasi dan biopsy sumsum tulang

• 28/12/2018 readmisi dengan keluhan lemas yg memberat sejak 1 mg SMRS, mual dan muntah. Bicara pelo/hemiparese-, demam sejak1 bulan (BB 64 kg, TB 170 cm)

• Lab tgl 27/12/2018 : Hb 7,2 gr/dl, Ht 21,8, Leuko 7600 (0/0/89/9/2), Tr 44.000

• DPL : Hb 8, Ht 21,7, MCV/H 77,8/28,7, Leuko 8240, Trombo 38.000

• Na/K/Cl 119/4,2/95

• Sitomorfologi ss tlg : hiperseluler, blast 3%, M:E Ratio 1,5 :1, eritropoiesis meningkat, granulopoiesis dan trombopoiesis menurun

• Imunotyping : blast 22%, morfologi : ALL-L3 Burkitt, gating pada blast : CD20 +, CD 19+ B lineage

• Histopatologi : hiperseluler, M:E ratio normal, seri myeloid maturasihingga segmen, megakariosit ditemukan. Tampak sel-sel berukuranbesar, berinti pleomorfik, vesikuler, anak inti nyata, sitoplasmaeosinofilik sesuai dengan Leukemia akut DD/ infiltrasi limfomamalignum non Hodgkin, sel besar

• Imunohistokimia : CD 20 + difus, CD3 -, CD 10 -, Ki67 + pada sekitar80%, MUM-1, PAX-5 +, TdT -, bcl6, CD34 tidak dapat diperiksainfiltrasi LNH, sel B, jenis sel besar, difus, subtype non GCB

• PET-CT Scan :

Multipel pembesaran KGB di upper dan lower diafragmatika disertai splenomegaly hipermetabolik (SUV max 10,3). Dijumpai keterlibatan extranodal lymphoma intra BM dan kecurigaan extranodal lainnya di daerah hepar (SUV max 6,1). Asitesintraperitoneal, efusi pleura bilateral terutama sisi kiri disertai dislektasis jaringanparu kiri normal diatasnya.

DLBCL, Non-GCB B-cell-like subtype stad 4

R-CHOP + CNS profilaksis (MTX IT)

4/1/19 6/1 8/1 10/1 14/1 21/1 25/1 13/2 13/9

Hb 9,2 8,3 6 7,1 9,3 9,7 9,8 9,4 12,3

Ht 25,8 23,4 17 20,8 26,7 29 29 38

leukosit 8739 5160 11640 3980 540 4600 5610 3100 8200

trombosit 20.000 7000 43.000 64.000 85.000 281.000 321.000 168.000 400.000

TC, R-miniCHOP TC TC R-CHOP II R-CHOP III

Summary

• Thrombocytopenia is a common hematologic finding with variable clinical appearance

• Can result from a wide range of conditions and determined by multiple mechanism

• A prompt and correct identification of the causes is crucial for the appropriate management

• Different approach between outpatients and acute thrombocytopenia in ED/ICU

• Thrombocytopenia in pregnancy deserves special consideration because of the possible consequences on the fetus

• Integration of clinical findings and laboratory support

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