Challenges With Diagnosis of ITP

James Bussel, MD: Craig, one of the things you’re highlighting is that we should do next-generation sequencing into marrow. Diagnosis of ITP [immune thrombocytopenia] is so primitive and pathetic. If you think of a leukemic who comes into the emergency department with thrombocytopenia, it turns out there are circulating blasts, you do this whole work-up, and divide them into 10 to 20 different types of leukemia. You have their treatment protocol all scripted out, including monitoring, and possibly things about what happens with relapse or nonresponse.

But if you take a patient with ITP who comes in, all we’ve agreed on is to do a complete CBC [complete blood count] and look at the smear. You could argue that in a younger woman there might be more autoimmunity. Craig, you were bringing up some of the issues in elderly patients. There is no consensus on which secondary ITP to look at. I think at the moment, that puts a tremendous amount of pressure on clinicians as to what subtle clues they could try teasing out, to then do a work-up for X, or Y, or Z. I think in the context of seeing patients with the clock ticking, with your next patient coming up, and if you’re late, Press Ganey [patient satisfaction surveys] will clobber you in the reviews, it’s really hard to integrate all that.

Craig Kessler, MD: Jim, I think you’re absolutely right that the diagnosis of ITP is often incorrect. We’ve seen and heard patients tell us about hereditary issues that turn out to be related to May-Hegglin anomaly. We’ve heard of issues where patients have had several problems, say with von Willebrand type 2B disease, as an example of misdiagnosis of ITP. You yourself have talked about many of the primitive immunologic abnormalities that are missed until they develop complications. You’re right, ITP is much more complicated than what we used to think of bread and butter hematology.

James Bussel, MD: Dr Piatek, do you want to channel your inner Howard Liebman MD, hematologist here or not?

Caroline Piatek, MD: Yes. I was going to say that another reason not to do a splenectomy would be that it might not be ITP.

Transcript Edited for Clarity