BMJ 2013;346:f3407 doi: 10.1136/bmj.
f3407 (Published 10 June 2013) Page 1 of 3
Practice
PRACTICE
10-MINUTE CONSULTATION
Thrombocytopenia in an adult
1
Jecko Thachil consultant haematologist , David Fitzmaurice professor of primary care clinical
2
sciences
Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL, UK; 2University of Birmingham,
1
Birmingham B15 2TT, UK
This is part of a series of occasional articles on common problems in recognised as antiplatelet agents, aspirin and clopidogrel
primary care. The BMJ welcomes contributions from GPs. do not cause thrombocytopenia, but they can exacerbate
the bleeding associated with lower platelet counts. The
A 40 year old woman visits her general practitioner with website www.ouhsc.edu/platelets provides a useful
symptoms of dyspepsia and increasing tiredness. On a routine comprehensive guide to drugs that may induce
blood count, her platelet count is noted to be 40×109/L with thrombocytopenia.
normal haemoglobin and white cell count. She has no medical
history and is not taking any medication. Clinical examination • Herbal remedies (such as Chinese herbal tea and tahini)
reveals no bruises or bleeding. are overlooked reasons for thrombocytopenia. Reports of
a precipitous drop in the platelet count have been noted
What issues you should cover? after ingestion of English walnuts. These cases are difficult
Ask about recent or current symptoms of bleeding, which are to diagnose, but ask about frequent intake of the above and
commonly epistaxis or easy bruising with minor trauma. advise abstinence if they might be causative.
Haematuria and gastrointestinal bleeding are unusual, but • Immune thrombocytopenia is a common cause of low
menorrhagia can be a common symptom. In general, a platelet platelet count in young adults and is often seen in young
count above 30×109/L is unlikely to cause bleeding unless women of reproductive age, who may also have symptoms
abnormal platelet function exists in the form of antiplatelet and signs of autoimmune diseases (such as thyroid disease,
agents or myelodysplasia. Substantial bleeding tends to happen systemic lupus erythematosus, and pernicious anaemia).
only if the count drops much below 20×109/L. Spontaneous In older adults, immune thrombocytopenia occurs with
intracranial haemorrhage secondary to thrombocytopenia usually equal frequency in both sexes.
occurs only with platelet counts less than 10×109/L. Further • Chronic liver disease, including cirrhosis, leads to
questions may be directed to identifying the possible causes of thrombocytopenia because of the lack of the platelet
thrombocytopenia. hormone thrombopoietin and associated splenomegaly.
Excess alcohol intake can also induce bone marrow
Pointers to diagnosis suppression, leading to thrombocytopenia.
• Recent viral infections (such as glandular fever) are • Hepatitis C and HIV infections can cause substantial
probably the commonest reason for a low platelet count in decrease in platelet count.
young adults.1 Occasional cases of moderate
thrombocytopenia have been reported after flu • Helicobacter pylori infection is increasingly being
vaccinations.1 Bacterial infections tend not to cause low recognised as a cause of thrombocytopenia, with some
platelet counts, unless associated with septicaemia. evidence that eradication may improve the platelet count.
• Many common drugs can lead to thrombocytopenia, • It is rare for bone marrow disorders such as leukaemia or
including H2 blockers, paroxetine, furosemide, and lymphoma to cause isolated thrombocytopenia (in the
metronidazole. A temporal relation between the decrease absence of other abnormalities in the full blood count).
in platelet count and the start of drug treatment is a clue. • In an otherwise healthy individual, thrombocytopenia may
In these cases, stopping the drug usually improves the be a laboratory artefact, caused by platelet clumping due
platelet count within a week, confirming the causality of to the anticoagulant used for blood collection. This
the thrombocytopenia by the drug. Although well phenomenon is not associated with any untoward
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BMJ 2013;346:f3407 doi: 10.1136/bmj.f3407 (Published 10 June 2013) Page 2 of 3
PRACTICE
consequences and is usually flagged up on an automated 50×109/L to avoid excess perioperative bleeding. For this reason,
analyser or easily identified by examination of a blood patients who may require surgery in the immediate future should
film. be referred to a specialist. Patients with counts above 50×109/L
• The presence of skeletal abnormalities or history of may need investigations and possibly treatment to allow them
recurrent infections and a family history of to continue taking “blood thinning” agents. Those whose platelet
thrombocytopenia are noted in the very rare inherited count is over 100×109/L may be monitored on a monthly basis,
platelet disorders. and if the count repeatedly remains over 100×109/L the
frequency of tests may be decreased. If there is shift to lower
• Rare conditions like thrombotic thrombocytopenic purpura counts, the patient may be referred on a non-urgent basis. All
and haemolytic uraemic syndrome can present with severe pregnant women with thrombocytopenia should be seen by
thrombocytopenia and associated haemolytic anaemia. specialists, who may have to make decisions about treatment,
Clinical symptoms can vary from being asymptomatic to sometimes early in pregnancy. The figure⇓ shows a flow chart
neurological disturbances such as headache and confusion to guide referral.
and renal impairment. Acute folate deficiency in older
individuals can also present with thrombocytopenia. A
thorough review of the blood film by an experienced
Outcome
observer can help in diagnosing or excluding these and The patient was tested for Helicobacter pylori infection, which
other underlying pathologies. came back positive. Successful eradication normalised the
• Tiredness is a recognised symptom of immune platelet count and the patient’s energy levels. A repeat blood
thrombocytopenia, which has been noted to improve with count three months later confirmed a normal full blood count.
increasing platelet count.
Competing interests: We have read and understood the BMJ Group
policy on declaration of interests and have no relevant interests to
What you should do? declare.
Examine the patient for any signs of bruising, which would Contributors: JT conceived and drafted the article. DF revised it critically
warrant urgent referral. Any history of bleeding—including for important intellectual content. Both authors approved the final version.
epistaxis, gum bleeds, or melaena—also requires urgent hospital Provenance and peer review: Not commissioned; externally peer
assessment, as does a platelet count below 30×109/L. Patients reviewed.
who are taking aspirin or other antiplatelet agents or warfarin
should stop these medications if there are signs of bleeding or 1 Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al.
International consensus report on the investigation and management of primary immune
if the platelet count is less than 50×109/L. thrombocytopenia. Blood 2010;115:168-86.
Patients with a platelet count above 50×109/L usually do not Accepted: 19 December 2012
have a high risk of bleeding and may be referred on a
semi-urgent basis (in about 2-4 weeks). For many surgical Cite this as: BMJ 2013;346:f3407
procedures, a safe platelet count is deemed to be at least © BMJ Publishing Group Ltd 2013
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BMJ 2013;346:f3407 doi: 10.1136/bmj.f3407 (Published 10 June 2013) Page 3 of 3
PRACTICE
Useful resources
For patients
PDSA: Platelet Disorder Support Association (www.pdsa.org/)—Information for patients with immune thrombocytopenia and other
platelet disorders, website based in the US
ITP Support Association (www.itpsupport.org.uk/)—UK based website for patients with immune thrombocytopenia.
For healthcare professionals
Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA, et al. American Society of Hematology 2011 evidence-based
practice guideline for immune thrombocytopenia. Blood 2011;117:4190-207, doi:10.1182/blood-2010-08-302984.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation
and management of primary immune thrombocytopenia. Blood 2010;115:168-86, doi:10.1182/blood-2009-06-225565.
Figure
Referral guideline for patients with thrombocytopenia. Urgent referral is within 24 hours, semi-urgent referral is ideally in
2-4 weeks, and routine appointments should in 2-3 months
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