SHM Converge Scientific Abstract ePoster Gallery-Two True and Unrelated: Inpatient Evaluation for Severe Thrombocytopenia

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This case highlights the importance of identifying the cause of thrombocytopenia because treatment differs substantially by etiology. The patient was a middle-aged man with hepatic cirrhosis who presented with mucosal bleeding, petechiae, and confusion. Initial evaluation showed profound thrombocytopenia (platelets 1,000/µL), anemia, elevated INR/PTT, low fibrinogen, and abnormal platelet antibodies. Although liver disease can cause thrombocytopenia through splenic sequestration, reduced thrombopoietin, and marrow suppression, the severity of this patient’s thrombocytopenia and failure to respond to repeated platelet transfusions suggested an additional process.<br /><br />The hospital course showed no platelet recovery after 20 platelet transfusions, IVIG, eltrombopag, or dexamethasone. His corrected count increment after transfusion was 0, indicating platelet transfusion refractoriness. He later improved only after romiplostim and rituximab, supporting a diagnosis of immune thrombocytopenia (ITP) superimposed on cirrhosis-related thrombocytopenia. His altered mental status resolved with bowel movements, suggesting hepatic encephalopathy rather than bleeding-related neurologic injury.<br /><br />The presentation emphasizes that thrombocytopenia in cirrhosis usually does not require treatment or transfusion unless a high-risk procedure is planned or active bleeding is present. By contrast, ITP is a diagnosis of exclusion and is treated first with steroids and IVIG, with second-line options including thrombopoietin receptor agonists and CD20 blockade. The case demonstrates multifactorial severe thrombocytopenia and the need to consider ITP when platelet transfusions repeatedly fail.

Asset Subtitle

Audrey Lane

Meta Tag

Author List Alex Nester, Audrey Lane

Category Clinical Vignettes

Concept Thrombocytopenia

Concept Immune Thrombocytopenia

Concept Cirrhosis

Concept Splenic Sequestration

Concept Thrombopoietin

Distinguished Non-Finalist

Presenter Organization University of Nebraska Medical Center, Children's Nebraska

Presenting Author Audrey Lane

Track Adult

Keywords

thrombocytopenia

cirrhosis

immune thrombocytopenia

platelet transfusion refractoriness

mucosal bleeding

petechiae

hepatic encephalopathy

romiplostim

rituximab

thrombopoietin receptor agonist

Thrombocytopenia

Immune Thrombocytopenia

Cirrhosis

Splenic Sequestration

Thrombopoietin