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LETTER TO EDITOR
Year : 2021  |  Volume : 10  |  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 Submission08-Mar-2021
Date of Acceptance14-May-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Dr. Suvir Singh
Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College, Ludhiana, Punjab - 141 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_457_21

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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

How to cite this URL:
Singh S. Not all thrombocytopenic bleeding is the same: Response to Singh et al. J Family Med Prim Care [serial online] 2021 [cited 2021 Sep 24];10:3165-6. Available from: https://www.jfmpc.com/text.asp?2021/10/8/3165/324732



Dear Editor,

Singh et al.[1] 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.[2] These patients need aggressive initiation of diagnosis and treatment to prevent the same.[3]

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.[4] 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.[5]

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.[6] 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.[7] 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.[8]

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh M, Singh V, Singh D, Bohra G, Misra A. Hemorrhagic manifestation in different etiologies of pancytopenia: A prospective, cross-sectional study. J Family Med Prim Care 2021;10:804-8.  Back to cited text no. 1
  [Full text]  
2.
Mishra K, Jandial A, Malhotra P, Varma N. Wet purpura: A sinister sign in thrombocytopenia. BMJ Case Rep 2017;2017:bcr2017222008.  Back to cited text no. 2
    
3.
Crosby WH. Editorial: Wet purpura, dry purpura. JAMA 1975;232:744-5.  Back to cited text no. 3
    
4.
Chang H, Kuo MC, Shih LY, Dunn P, Wang PN, Wu JH, et al. Clinical bleeding events and laboratory coagulation profiles in acute promyelocytic leukemia. Eur J Haematol 2012;88:321-8.  Back to cited text no. 4
    
5.
Breen KA, Grimwade D, Hunt BJ. The pathogenesis and management of the coagulopathy of acute promyelocytic leukaemia. Br J Haematol 2012;156:24-36.  Back to cited text no. 5
    
6.
Gu C, Zhu X, Qiao X, Zhai X, Shi W, Xie X. Multivariate logistic analysis of predictors of response to immunosuppressive therapy in children with aplastic anemia: A double-center study. Hematology 2019;24:282-9.  Back to cited text no. 6
    
7.
Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2020;104:79-87.  Back to cited text no. 7
    
8.
Gupta V, Pratap R, Kumar A, Saini I, Shukla J. Epidemiological features of aplastic anemia in Indian children. Indian J Pediatr 2014;81:257-9.  Back to cited text no. 8
    




 

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