|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 8 | Page : 3165-3166
Not all thrombocytopenic bleeding is the same: Response to Singh et al.
Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College, Ludhiana, Punjab, India
|Date of Submission||08-Mar-2021|
|Date of Acceptance||14-May-2021|
|Date of Web Publication||27-Aug-2021|
Dr. Suvir Singh
Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College, Ludhiana, Punjab - 141 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh S. Not all thrombocytopenic bleeding is the same: Response to Singh et al. J Family Med Prim Care 2021;10:3165-6
Singh et al. report a relevant study describing the risk of bleeding in patients with various etiologies of pancytopenia. These data have significance in day-to-day practice and highlight several crucial concepts. Extending the discussion, we highlight three important practical points in patients with thrombocytopenia secondary to acute leukemia and aplastic anemia.
First, although a majority of patients with acute leukemia or aplastic anemia present with minor bleeding, several patients are at risk of more severe bleeds and candidates for aggressive interventions. The presence of wet purpurae, that is, blood-filled blisters in the oral cavity must be looked for in all patients, as they are shown to predict for central nervous system (CNS) bleeding. These patients need aggressive initiation of diagnosis and treatment to prevent the same.
Second, the presence of leucocytosis or blasts on peripheral smear in a thrombocytopenic patient prompts evaluation for acute leukemia, which usually proceeds over the next 24–48 h. However, the presence of acute promyelocytic leukemia (APML) must be urgently excluded, as over 70% of patients with APML can present with disseminated intravascular coagulation (DIC) at diagnosis. CNS bleeding is a common cause of early deaths in APML, and can be prevented with appropriate transfusions and initiation of therapy. For all patients with acute leukemia, while specific evaluation is awaited, a peripheral smear must be reviewed to look for the presence of abnormal promyelocytes, and DIC must be ruled out with a baseline prothrombin time (PT), activated partial thromboplastin time (aPTT) and fibrinogen.
Third, local measures are effective in controlling oral and nasal bleeding in most patients with thrombocytopenia and can avoid unnecessary platelet transfusions for minor bleeding. The number of platelet transfusions has an inverse correlation with outcomes after an immunosuppressive therapy or stem cell transplantation. The use of topical antifibrinolytic agents such as tranexamic acid is particularly effective and can be administered in the form of soaked gauzes, mouthwash or crushed tablets applied locally. Up to 80% of patients with aplastic anemia in India can present with minor bleeding, and avoiding unnecessary platelet transfusions can reduce the cost and complications of treatment.
Most importantly, this study reaffirms the important concept that all patients with pancytopenia are not equal, and require varied approaches to evaluation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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