(All the articles published in past are available at www.shyamhemoncclinic.com)
Question: Dr. Chiragbhai, thank you for explaining in last part about approach to pancytopenia – a common but difficult issue. Early bone marrow examination (including biopsy, not just aspirate) is critical in diagnosis, as many of the diseases that present with pancytopenia are potentially serious. Also important was the point that bone marrow biopsy can be done at any level of platelet count, even if less than 5000, hence there is no need to wait or give platelets. One very common issue in our region is thrombocytopenia – low platelets. Can you tell us about how to approach this problem?
Ans: Definitely. This is a very common issue, and especially common during outbreaks of dengue and malaria. Just like anemia, differential diagnosis is very wide, and given in books. Our goal is to discuss systematic approach, which leads to timely diagnosis and emergency management when required, for better patient outcomes. There are many ways to classify thrombocytopenia causes. But a major concern in clinician’s mind at first is often risk of bleeding rather than underlying cause. So, I suggest following steps:
Cause evaluation i.e. initiate work up for probable causes, especially the serious ones.
Assess bleeding risk. Are there additional reasons for bleeding, such as coagulopathy, medicines etc.
Transfusion – decide need and goal count. Most patients do not need platelet transfusion.
Treat underlying disease and other required care.
Que: So, CATT is the way to go. Can you elaborate more for our readers?
Ans: Yes. It is important to initiate basic work up while you start ordering platelet transfusion. It is sometimes a reflex action in busy practice that low platelet count is treated with platelet transfusion, but no work up is initiated. Next day patient has same count or is even more sick and then work up is considered.
Low platelet count in many diseases by itself is not at serious levels, such as about 50,000 but the underlying disease could be very serious. Some of these which should not be missed are: acute leukemia, sepsis (may present without other signs in elderly or with severe burns or renal failure and others), HITT (heparin induced), TTP (thrombotic thrombocytopenic purpura). Now as you can see, platelet count of 50,000 by itself is not serious, but above noted diseases untreated can be potentially fatal in a matter of days.
So, let us cover following issues:
• Grades of thrombocytopenia – helpful in determining urgency and extent of evaluation, and transfusion, when to call patient back for follow up versus admit.
• What not to miss: serious causes, which need immediate attention.
• Microscope’s role.
• Transfusion-when, what, how much, contraindications for transfusion.
• Myths – such as aspirin, renal failure etc.
• What is new?
Que: That seems like very comprehensive discussion. Can you tell us more about grades?
Ans: Yes. I have tried to create approach as in real life practice. When a clinician sees a patient with low platelet, he may be either looking very sick when decision making is easy, you just admit patient or refer to a higher center. But the ones who do not look sick, are the ones where you have to make important decisions – when to call them back, how many tests to order, what is the prognosis etc.
I believe the grades of thrombocytopenia help to guide in this situation (not a guarantee, clinical judgment is always important). 4. <10,000 – Super severe 3. 10,000-30,000 – Severe 2. 30,000-1,00,000 – Moderate
1. 1,00,000-1,50,000 – Mild. So, for grade 4 – admission and aggressive work up is reasonable, including referral to a hematologist. If patient has classical signs of seasonal issue such as Dengue, a limited work up can be done. January 15th 2014.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. email@example.com Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com