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14-02: Thrombocytopenia

Andrew D. Leavitt; Erika Leemann Price; Tracy Minichiello

Selected causes of thrombocytopenia are shown in Table 14–2. The age of the patient and presence of comorbid conditions can help direct the diagnostic workup.

Table 14–2.Selected causes of thrombocytopenia.
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Table 14–2. Selected causes of thrombocytopenia.

Decreased production of platelets

 Congenital bone marrow failure (Fanconi anemia, Wiskott-Aldrich syndrome; congenital amegakaryocytic thrombocytopenia)

 Acquired bone marrow failure (aplastic anemia, myelodysplasia, leukemia)

 Exposure to chemotherapy, irradiation, medications (https://ouhsc.edu/platelets/ditp.html)

 Marrow infiltration (neoplastic, infectious)

 Nutritional (deficiency of vitamin B12, folate)

 Other: HIV infection, alcohol

Increased destruction of platelets

 Immune thrombocytopenia (primary)

 Immune thrombocytopenia (secondary), including drug-induced or related to lymphoproliferative disorders (eg, CLL, hepatitis C virus, Epstein-Barr virus, or HIV)

 Heparin-induced thrombocytopenia

 Thrombotic microangiopathy

 Disseminated intravascular coagulation

 Posttransfusion purpura

 Neonatal alloimmune thrombocytopenia

 Mechanical (aortic valvular dysfunction; extracorporeal bypass)

 von Willebrand disease, type 2B

 Hemophagocytosis

Increased sequestration of platelets

 Hypersplenism (eg, related to cirrhosis, myeloproliferative disorders, lymphoma)

Other conditions causing thrombocytopenia

 Gestational thrombocytopenia

 Bernard-Soulier syndrome, gray platelet syndrome, May-Hegglin anomaly

 Pseudothrombocytopenia

CLL, chronic lymphocytic leukemia.

The risk of clinically relevant spontaneous bleeding (including petechial hemorrhage and bruising) does not typically increase appreciably until the platelet count falls below 10,000–20,000/mcL, although patients with dysfunctional platelets or local vascular defects can bleed with higher platelet counts. Suggested platelet counts to prevent spontaneous bleeding or to provide adequate hemostasis around the time of invasive procedures are found in Table 14–3. However, most medical centers develop their own local guidelines to have a consistent approach to such complex situations.

Table 14–3.Desired platelet count ranges.
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Table 14–3. Desired platelet count ranges.
Clinical Scenario Platelet Count (/mcL)
Prevention of spontaneous mucocutaneous bleeding > 10,000–20,000
Insertion of central venous catheters > 20,000–50,0001
Administration of therapeutic anticoagulation > 30,000–50,000
Minor surgery and selected invasive procedures2 > 50,000–80,000
Major surgery > 80,000–100,000

1A platelet target within the higher range of the reference is required for tunneled catheters.

2Such as endoscopy with biopsy.

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