Signs and symptoms suspicious for ITP

What signs or symptoms should raise the suspicion of immune thrombocytopenia (ITP)?

Bertrand Godeau, MD, PhD: In the majority of cases ITP is a primary isolated disease—in contrast with hemolytic anemia, because hemolytic anemia in 50% of cases is associated with other diseases such as lymphoma or autoimmune disease. ITP in 80% of cases is a primary ITP. Its unique symptoms are bleeding, purpura, bleeding in the mouth, epistaxis. In 20% of patients ITP can be associated with other autoimmune disease, and particularly with systemic lupus, antiphospholipid syndrome, or Sjögren disease. So clearly if you have ITP with arthralgia, splenomegaly, or sicca syndrome, in this case you must test for lupus. But our practice is to systematically test patients with ITP for antinuclear antibody, because if you have a high level of antinuclear antibody, it is clear that in this case [your patients do not have] primary ITP and you must suspect lupus or other autoimmune disease.

In contrast, it is very rare for patients with ITP to have lymphoma or chronic lymphocytic leukemia (CLL). It is clearly totally different with hemolytic anemia. But you must test your patient for HIV infection, because as you know there is a link between autoimmune cytopenia and HIV, and—in my experience—CVID, common variable immunodeficiency disease. So our policy or practice is to systematically test the patient for the gamma globulin level, because if you have a low gamma globulin level, you suspect CVID, and if you have a high gamma globulin level, you suspect lupus or sicca syndrome.