Hello Radi,

Thanks for the query at DoctorSpring.

I understand that your husband has been suffering from low platelet count (thrombocytopenia) due to possible ITP.

In regard to your question, the normal platelet count ranges from 150000 to 450000 /ul.
If the level falls 100000/ul it is termed as thrombocytopenia. However levels than 50000/ul causes posttraumatic bleeding and less than 20000/ ul causes spontaneous bleeding, fundal and intracranial bleeding. So with his present level less than 30000, there are risks of bleeding even following a minor trauma. Luckily the bleed he had in calf is not very harmful, but that might not be the case every time. For example a bleeding in the brain can be catastrophic.

So should we rush into splenectomy and the bone marrow test? – You should go for the bone marrow test as soon as possible.  This is to rule out any other condition that may cause low platelets and will help in forming a final diagnosis of ITP. You need not ‘rush’ into splenectomy, but it needs to be considered as your husband is not having persistent response with Prednisolone, IVIG or having a spontaneous remission. Ideally one can wait 4-6 weeks before splenectomy to see whether the counts return normal. But in your husband’s scenario, I would recommend to trust your Doctors judgement. With the limited information I also feel that splenectomy is the best way to move forward. Other second line options are not as effective as splenectomy. When done electively this is a safe procedure.  

Splenectomy acts by removing the major site of platelet destruction and brings down the concentration of circulating antiplatelet antibodies. It is a safe procedure. Side effects like infections (OPSI), fever may occur in certain individuals, but they are manageable. Your Doctor will recommend some immunization prior to the procedure. IVIG can be used but provide only temporary effect. So it would be best to go for a long-term solution. The count should be near normal. At least should be above 50,000 to prevent chances of bleed.

Hope this helps.

Please feel free to ask followup questions via email itself.

Thank you.

Hello, 

Do you have any of his previous blood test value with you ? - Especially of the WBC count.

Also if you have a "Peripheral Smear Report" please share with me. 

Thank you

Hello,

Thank you for the additional details. 

The reports in general shows two abnormalities. 1.Low platelets (which we already know) 2.High WBCs.

WBCs are supposed to go up when there is an infection or inflammation. It is their function. So we cannot call it exactly 'abnormal'. Even drugs like prednisone can cause this. A peripheral smear should have been done already. If you are under the care of a Hematologist, he/she might have observed seen it directly under microscope. 

So the low platelet count is the main concern in the blood tests. Rest can be considered as a soft finding for now. 

Bone Marrow test is a not a complicated procedure. Side effects are rare. You SHOULD go for it and SHOULD NOT delay it if your Doctor has recommended it. It is a very common procedure done in Haematology on a daily basis. 

Hope this helps

Thank you

Hello,

Thank you for the followup.

Rituximab is a second line drug. So naturally the side effects might be bit more than traditional drugs ( that is why it is kept as second line). However this should not deter you from making a decision. Side effects can occur even with simple pain medication, so there is no logic in being overly concerned. 

Rituximab can be effective upto 40% of patients. However the issue is how long the effect will last. Usually splenectomy is considered in line with Rituximab. (Not always like Splenectomy if Rituximab fails, although nothing wrong in this approach) . So one consideration here is where he should go for Splenectomy straight away. This I will not be able to make any recommendation, only your treating Doctor can. So please discuss this with your Doctor .

Thank you

Wish you good health