Idiopathic Thrombocytopenic Purpura (ITP) Topic Review and Case Report

Idiopathic thrombocytopenic purpura (ITP) is an abnormal decrease of platelets of unknown etiologic causes. Clinical manifestations include muco-cutaneous bleeding (petechia, purpura, ecchymosis), epistaxis and/or GI bleeding. Diagnosis is made by exclusion of other causes e.g. lab error, drug or medication interaction or an infection. Prevention and control of bleeding is the most important action to do before treating the condition. This is done by transfusion of platelets. The treatment consists of steroid therapy, Anti-D immunoglobulin [1,2,3], Thrombopoietin receptor agonists or even splenectomy in some severe cases. We are presenting a case of severe ITP that was identifi ed in our dental clinic for an initial screening, our patient was admitted to the hospital and treated successfully with steroids, he presented with multiple oral and cutaneous lesions. Case Report Idiopathic Thrombocytopenic Purpura (ITP) Topic Review and Case Report Mohamed Ahmed1* and Alan Y Martinez2 1Department of Oral Health the MetroHealth System, Cleveland, Ohio, USA 2Director, division of Oral and Maxillofacial Surgery. Department of Oral Health, the MetroHealth System, Cleveland, Ohio, USA Dates: Received: 11 January, 2017; Accepted: 04 February, 2017; Published: 08 February, 2017 *Corresponding author: Mohamed Ahmed, Resident. General practice residency. Department of Oral Health. The MetroHealth System. Cleveland, Ohio, USA, Emailm1adel2@gmail.com


Introduction
ITP is an acquired disorder that mainly affect the platelet count in the blood. Platelets are small colorless disk-shaped cell without a nucleus, it can found in great quantities in blood and are involved in clotting ( Figure 1). ITP can be classifi ed as acute, chronic or recurrent [5]. The acute form is a temporary condition, which persists for less than 3 months and affects mainly children while the chronic stage might last more than 12 months and affects adults more, the recurrent form is multiple incidents of thrombocytopenia in the period of over 3 months. Corticosteroids or I.V Immunoglobulin can treat idiopathic thrombocytopenia. ITP results from an auto-immune mechanism or from impaired thrombopoiesis.
The literature shows that some ITP patients have plateletassociated autoantibodies in their blood [6]. Also, other patients have B-cells that produce antibodies attacking normal platelet antigens due to signal from CD4 T cells [7]. Another study demonstrates an increase in NK cells in patients with ITP. On the other hand, in vitro study showed suppression of megakaryopoies by autoantibodies in other ITP patients [8].
Also, the thrombopoietin, which regulates platelet production, is suggested to have an infl uence on the level of platelet count in blood.
Diagnosis of such cases relays mainly on the history, clinical and physical examination of the patient and Complete blood count. There might be different factors could lead to ITP.
Patients at risk of HIV infection should be tested for antibodies [9].
To achieve a precise diagnosis, we should differentiate between ITP and TTP (thrombotic thrombocytopenic purpura  The pain was severe with rating 9 out of 10 and unable to eat. Full clinical examination of these lesions revealed that they tend to bleed easily upon touch with granulation tissue all over them. They have a recent onset about a week ago which was confusing in the diagnosis. A consultation with the oral and maxillofacial surgery division was requested. Lab tests were ordered on the spot involving complete blood count, Prothrombin time and Partial prothrombin time. Tests revealed a massive drop in the platelets count, which was 2000 per microliter (normal values range from 150,000 to 400,000).
The lab requested another sample to confi rm the diagnosis and it was 1,000 platelet per microliter [ Table 1]. The patient was admitted to the hospital to stabilize the condition. More blood samples were obtained and immediate platelet transfusion was started.
The pain was severe with rating 9 out of 10 and unable to eat. Full clinical examination of these lesions revealed that they tend to bleed easily upon touch with granulation tissue all over them. They have a recent onset about a week ago which was confusing in the diagnosis. A consultation with the oral and maxillofacial surgery division was requested.
Lab tests were ordered on the spot involving complete blood count, Prothrombin time and Partial prothrombin time. Tests revealed a massive drop in the platelets count, which was 2000 per microliter (normal values range from 150,000 to 400,000).
The lab requested another sample to confi rm the diagnosis and it was 1,000 platelet per microliter [ Table 2]. The patient was admitted to the hospital to stabilize the condition. More blood samples were obtained and immediate platelet transfusion was started.
Subsequently, the patient was diagnosed with Idiopathic thrombocytopenia purpura and type II diabetes.
The initial plan from the ED on 8/12/2016 was as follows:  This safe level is from 30,000 to 50,000 platelet [15]. In such situations when platelet count needs to be increased rapidly, high dose methylprednisolone treatment can be used [16].