Case Presentation: A 78-year old male with a past medical history of COPD arrived to the hospital with bleeding in his mouth that had started two days prior to admission. Patient had reported taking ciprofloxacin from his primary care physician for a urinary tract infection in those two days. Patient’s initial platelet count was 11,000/mcL and had a normal metabolic panel.Patient was admitted for thrombocytopenia. Initial physical exam showed stable vital signs, no signs of confusion, and multiple oral hematomas without acute bleeding. 1 Day after admission, his platelet count declined to 7,000/mcL with normal coagulation studies. Peripheral smear found no fragmented red blood cells and enlarged platelets. Patient was monitored for spontaneous bleeding. In the afternoon, medicine team was notified by nursing that the patient’s blood pressure dropped to 70/40 and altered mentation. Patient was sent to the ICU where he was started on IV norepinephrine and BiPAP. A full body CT scan was done and revealed no bleeding. Patient’s mentation and blood pressure improved. Hematology was consulted and confirmed ITP. Patient given IV dexamethasone 40 mg. Patient’s platelet count did not improve with 4 days of steroids. IVIG was given instead and platelets improved to 158,000/mcl in 6 days. Patient’s ITP was suspected to be associated with ciprofloxacin given use prior to admission, recovery after cessation, and alternative causes were excluded.
Discussion: ITP can be a difficult condition to assess since it is a diagnosis of exclusion. Careful history should be taken to find any inciting factor since secondary ITP can be caused by medications especially antibiotics. Fluoroquinolones are a family of antibiotics used for broad-spectrum coverage of bacterial infections. Known side effects include tendinopathy, neuropathy, cardiac conduction abnormalities and rarely, ITP. Normal treatment protocol for ITP begins with removing the inciting factor and platelet transfusion as needed but can escalate with IV steroids or IVIG with a platelet count less than 10,000/mcl. In our case, with a lack of response to steroids, a dose of IVIG was given and the ITP improved. Research in the management of ITP showed IV steroids and IVIG to be equally effective with IVIG working more rapidly than steroids1. Consensus between the two treatments is that either can be used and when one treatment fails the other can be used2. This case helps to reinforce that perspective and shows its effectiveness.
Conclusions: Clinicians should take a thorough history when assessing a patient with severe thrombocytopenia to find any inciting factors especially medications. Assessment of ITP should involve hematology and a peripheral smear. Frequent clinical re-assessments are indicated in patients with severe thrombocytopenia to monitor adverse events such as spontaneous bleeding. Lastly, the management of ITP should begin with either IV steroids or IVIG depending on treatment response and should be adjusted in the setting of treatment failure.