An elderly gentleman is sent to the emergency department by his primary care physician. He complains of dark intraoral lesions that he has noticed appearing and disappearing over the past 2-3 days. He also complains of generalized weakness and dark, foul-smelling stools.
What is the diagnosis?
Idiopathic Thrombocytopenic Purpura (ITP)
The patient was diagnosed with ITP, likely related to an underlying (and previously unknown) pulmonary malignancy. Further skin exam revealed diffuse petechiae covering the lower extremities. His platelet count was 5 x 10^9/L and he was found to have acute blood loss anemia because of an ongoing upper GI bleed.
The intra-oral purpuric lesion seen in this patient (at right) is most commonly known as “wet purpura” (also known as hemorrhagic bullae). Hemorrhagic bullae are a clinical exam finding associated with ITP. While “dry-purpura” such as bruising and petechiae are indicative of low or dysfunctional platelets, wet purpura has clinical significance in that the patient is actively bleeding. Patients with wet purpura are at serious risk for life-threatening hemorrhage in the gastrointestinal tract or the brain. First line treatment for ITP is steroids. However, if the patient is actively bleeding, the recommended treatment is platelet transfusion together with IVIG administration to prolong circulating platelet half-life.