Nishant Rajendra Tiwari – My 12-Step Thrombocytopenia Workup
Nishant Rajendra Tiwari, Hematology-Oncology Fellow at OU Health Stephenson Cancer Center, posted on X:
”My 12-Step Thrombocytopenia Workup
(Not Medical Advice)
1. Review baseline counts first. Rule out pseudothrombocytopenia.
2. Evaluate for critical conditions: TTP, HIT, or DIC?
• Assess heparin exposure – Calculate 4T score.
• Peripheral smear for schistocytes.
• Check LDH/Haptoglobin/Bilirubin, PT/aPTT/Fibrinogen.
3. Assess for acute leukemia or bone marrow involvement?
• Examine peripheral smear for abnormal/neoplastic cells.
• Consider imaging if clinically indicated.
• Do we need a bone marrow exam?
4. Active life-threatening bleeding? Do we need a platelet transfusion?
5. Review drug-induced thrombocytopenia. Always consult latest literature for implicated medications.
6. Investigate secondary causes:
• Nutritional deficiencies: B12, Folate, Copper, Zinc.
• Infections: HIV, Hepatitis, CMV, EBV, HSV (clinically guided).
• Sepsis leading to DIC.
• Endocrine disorders: TSH, Free T4.
7. Review imaging for cirrhosis/splenomegaly. If inconclusive, obtain abdominal ultrasound.
8. Consider mechanical causes: Dialysis/ECMO/IABP/cardiopulmonary bypass/artificial heart valve?
9. Evaluate pregnancy-related disorders: HELLP, AFLP, gestational thrombocytopenia.
10. Assess for autoimmune conditions if clinically warranted. Consider SLE and other rheumatological diseases.
11. Consider rare but serious differentials:
• CAPS, other TMA causes, PNH
• Post-transfusion purpura, HLH
• Pursue only with appropriate clinical suspicion
12. If no clear etiology identified, consider ITP as diagnosis of exclusion.
Key Clinical Considerations:
• Critically ill patients frequently have multifactorial thrombocytopenia [A combination of some of the above].
• Primary HLH presenting de novo in adults is exceedingly rare.
• Thrombocytopenia with thrombosis: Consider DIC, TTP, HIT, PNH, or VITT.
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