A 28-year-old man is evaluated in the primary care office for new onset rash on both legs for 1 week. He is a healthy person with no past medical illness and is not taking any medications. There is no history of recent fever but he has noticed occasional gum bleeding and one episode of nosebleed 4 days ago. He does not smoke, drinks alcohol only socially, and does not use any recreational drug. On physical examination, he is a healthy appearing man with no lymphadenopathy or hepatosplenomegaly. Laboratory studies reveal hemoglobin 14.8 gm/dL, hematocrit 42, MCV 86 fL, leukocyte count 6,000/mL, and platelet 22,000/mL. Liver function and renal function studies are normal. Peripheral smear reveals decrease in platelet count and no red cell abnormalities. What is the most probable diagnosis?
Correct Answer: Immune thrombocytopenic purpura
Description: Chronic lymphocytic leukemia is monoclonal proliferation of mature lymphocytes, often found incidentally during routine checkup. Some patients may have constitutional symptoms such as weight loss, fever, night sweats, and fatigue. Painless lymphadenopathy is the most common physical finding. Hepatosplenomegaly can occur as well. Lymphocytosis is the most striking feature, and peripheral smear usually contains numerous mature lymphocytes. Bone marrow usually contains lymphocytes accounting for >30% of all nucleated cells.Immune thrombocytopenic purpura is a common cause of thrombocytopenia in otherwise normal individual; it is caused by immune-mediated destruction of platelets by antibodies against platelet antigens. Other causes of thrombocytopenia including sepsis, viral and other infections, drugs, pregnancy, liver disease, and hypersplenism should be ruled out. Patients may present with petechiae, purpura, epistaxis, or severe hemorrhage. Glucocorticoids and intravenous immune globulin (IVIG) are usually the first choice to treat this condition. Anti-D (RhoGAM) can be used instead of IVIG in patients with Rh-positive blood. Thrombotic thrombocytopenic purpura (TTP) usually presents with microangiopathic hemolytic anemia, nonimmune thrombocytopenia, fever, renal insufficiency, and CNS involvement. The peripheral smear in TTP contains schistocytes and decreased number of platelets.Hemophilia is an X-linked recessive disorder resulting is Factor VIII or Factor IX deficiency. It mainly manifests as bleeding in joints, muscles, subcutaneous tissue, and from the gastrointestinal tract; the bleeding may be spontaneous or trauma-related, depending on the severity of deficiency. A normal platelet count and prothrombin time but prolonged activated partial thromboplastin time (aPTT) are suggestive of hemophilia. Mild cases may escape detection until adulthood. Obtaining a detailed family history is very important. Specific assays for Factor VIII and Factor IX will confirm the diagnosis.Acute lymphoblastic leukemia is primarily a malignancy of childhood and young adulthood and presents commonly with bone pain and lymph-adenopathy. The peripheral smear and bone marrow usually contain a large number of lymphoblasts. Leukemoid reaction is a reactive leukocytosis with increased number of myelocytes, metamyelocytes, and bands in the peripheral circulation.
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