Thrombocytopenia: the good, the bad and the ugly

First Report of Ethylenediaminetetraacetic Acid-Dependent Pseudo-Thrombocytopenia in Chile: Prevalence and Laboratory Insights

Background: Ethylenediaminetetraacetic acid-dependent pseudo thrombocytopenia (EDTA-PCTP) is defined as a false in vitro decrease in the platelet count performed in the EDTA tube due to the spontaneous formation of platelet aggregates that prevent a correct count in hematological auto analyzers. The frequency of EDTA-PCTP varies depending on the population studied, ranging from 0.01% to 30.0%. In Chile, although the diagnosis of this condition is performed in clinical laboratories, only a few isolated reports have been described. Objectives: To determine the prevalence of EDTA-PCTP in a cohort of patients who attended an outpatient clinical laboratory in southern Chile over a period of almost 4 years. Methods: A retrospective analysis was conducted using the Laboratory Information System from January 2021 to November 2024 to identify patients with suspected and confirmed cases of EDTA-PCTP. Results: The prevalence rate observed was 0.044% (12 out of 27,480). Additionally, we established that platelet count measurement from the citrate tube at 2-5 h post-sampling was comparable to the platelet count from the EDTA/K2 tube at time 0 (p > 0.05) in these patients. Conclusions: We conclude that a relatively low prevalence of EDTA-PTCP was identified in a population of patients attending an outpatient laboratory in Chile, marking the first report of its kind in our country. Future studies may validate our findings to enhance understanding of EDTA-PTCP, thereby preventing incorrect diagnoses and treatments.

From Petechiae to Intracerebral Hemorrhage: A Rare Progression of Pediatric Idiopathic Thrombocytopenia

A four-year-old boy presented with a four-week history of hematuria, melena, and ecchymoses on his forehead, arm, and back, as well as upper respiratory symptoms. The physical examination revealed diffuse purpura on the lips, pallor, and several hyperpigmented spots. Laboratory results showed microcytic hypochromic anemia, neutropenia, lymphocytosis, and severe thrombocytopenia. A peripheral smear revealed giant platelets and a bone marrow biopsy revealed enhanced megakaryocytes with aberrant maturation. Despite the initiation of prednisolone medication, the patient experienced generalized tonic-clonic seizures and diminished consciousness (Glasgow Coma Scale: 4/15). Neuroimaging revealed a left-sided intracerebral hemorrhage with a midline shift, requiring an immediate decompressive craniotomy. Early detection and rapid interdisciplinary management are critical for improving outcomes in these life-threatening conditions.

Recent advances in the management of immune thrombocytopenic purpura (ITP): A comprehensive review

Autoimmune disorders place a substantial burden on the healthcare system all over the world affecting almost 3% to 8% of the population. Immune thrombocytopenic purpura (ITP), also known as idiopathic thrombocytopenic purpura, is a blood disorder in which the body immune system destroys platelets, leading to low platelet counts in the blood (peripheral blood platelet count < 150 × 109/L). Although the pathophysiology of ITP is not fully understood, it is believed to result from a complex interplay between hereditary and environmental variables. Certain factors, such as a low platelet count, history of bleeding, and certain comorbidities can increase the risk of severe bleeding in patients with ITP. Corticosteroids, intravenous immunoglobulin (IVIG), immunosuppressants, rituximab, and thrombopoietin receptor agonists (TPO-RAs) are some of the advanced treatments for ITP. Although these therapies may be successful, they also carry the risk of negative effects. Recently, significant advancements have been made in the understanding and treatment of ITP. There is still much to learn about the disease, and new, more effective treatments are needed. This comprehensive review offers a comprehensive assessment of recent advancements in ITP management, with a focus on active research projects, novel therapeutic targets, new treatment modalities, and areas of uncertainty and unmet needs. According to research, it is crucial to develop individualized treatment plans for ITP patients based on their age, platelet count, risk of bleeding, and comorbidities. The article also looks at how future developments in gene editing, bispecific antibody therapies, and cellular therapy may completely change the treatment of ITP.

A Rare Case of Relapsed Sarcoidosis Presenting As Severe Thrombocytopenia Associated With Intracerebral Hemorrhage Due to Bone Marrow Involvement

Sarcoidosis is a systemic granulomatous disease characterized by the hyperactivation of CD4 T cells, CD8 T cells, and macrophages. Clinical presentations of sarcoidosis are highly variable. Sarcoidosis is unknown in its etiology, but it suggests it may result from exposure to specific environmental agents in genetically susceptible people. Sarcoidosis commonly involves the lungs and lymphoid system. Bone marrow involvement in sarcoidosis is uncommon. Sarcoidosis rarely results in intracerebral hemorrhage due to severe thrombocytopenia secondary to bone marrow involvement. We present the case of a 72-year-old woman who has been in remission from sarcoidosis for 15 years and developed intracerebral hemorrhage secondary to severe thrombocytopenia due to sarcoidosis recurrence in the bone marrow. The patient presented to the emergency department with a generalized, non-blanching petechiae rash and nose and gum bleeding. Her labs showed a platelet count of less than 10.000/mcL, and computed tomography (CT) showed intracerebral hemorrhage. A bone marrow biopsy revealed a small, non-caseating granuloma indicative of a sarcoidosis relapse in the bone marrow.

Severe hematuria in a patient receiving bevacizumab and pembrolizumab for metastatic cervical cancer: a case report

BACKGROUND

Bevacizumab is a monoclonal antibody drug targeting Vascular Endothelial Growth Factor (VEGF), which binds to VEGF receptors to inhibit vascular endothelial cell proliferation and angiogenesis, thus inhibiting tumorigenesis. Pembrolizumab is a monoclonal antibody that can bind to the programmed death-1 (PD-1) receptor, which can block the binding of the PD-1 receptor to its ligands PD-L1 and PD-L2, and release PD-1 pathway-mediated suppression of immune responses. By blocking the activity of PD-1, the purpose of inhibiting tumor growth is achieved.

CASE PRESENTATION

We report a severe hematuria of bevacizumab plus pembrolizumab, in a 58-year-old woman with metastatic cervical cancer. After three cycles every three weeks of consolidation chemotherapy (carboplatin, paclitaxel, bevacizumab) and following three cycles consolidation chemotherapy (carboplatin, paclitaxel, bevacizumab, pembrolizumab), the patient presented a worsening state. Manifested as massive gross hematuria with blood clots. After stopping chemotherapy, cefoxitin, tranexamic acid and hemocoagulase atrox therapy was administered resulting in rapid clinical improvement. The patient was a cervical cancer with bladder metastasis that increases the risk of development of hematuria. Inhibition of VEGF, which has anti-apoptotic, anti-inflammatory, and pro-survival influences on endothelial cells, weakens their regenerative capacity and increases expression of proinflammatory genes leading to weakened supporting layers of blood vessels and, hence, to damaged vascular integrity. In our patient, the development of hematuria may result from the anti-VEGF effect of bevacizumab. In addition, pembrolizumab may also cause bleeding, and the mechanism of bleeding caused by pembrolizumab is currently unclear, which may be related to immune mediation.

CONCLUSION

To our knowledge, this is the first case reporting on the development of severe hematuria during bevacizumab plus pembrolizumab treatment, which should alert the clinicians in case of bleeding adverse events onset in older patients under bevacizumab plus pembrolizumab therapy.