3. 42yo female asian american with breast lump right breast. H/O ecchymosis.
Bleeding in skin and epistaxis and menorrhagia.
Platelet count 10,000. Large and few platelets.
Platelets given
ANA negative.
ESR normal
No hepatosplenomegaly.
UA normal.
BUN creatinine normal.
Prednisone started.
Plt count increased.
Bleeding stopped.
Pt discharged.
Not cleared for surgery yet for breast biopsy.

The patient is a 42-year-old Asian-American lady with a breast lump. Just by listening to this, one would think that the patient needs a breast biopsy. Obviously a mammogram in between would be a helpful risk stratifier in case the biopsy comes out negative.

Here the twister is that the patient has a history of ecchymosis which means that the patient has a bleeding tendency. Ecchymosis is usually not due to a clotting disorder but can be either due to a platelet disorder or due to vasculitis. One such vasculitic condition is seen in rheumatic fever when one inflates a blood pressure cuff onto the arm the patient gets ecchymosis and this is sometimes called Rumpell sign. In this case, the platelet count is only 10,000 - with abnormal morphology of the platelets, both large and few platelets, one obviously should think as soon as one sees large platelets that is patient has idiopathic thrombocytopenic purpura (ITP) which is commonly a cause of large platelets and thrombocytopenia. With a platelet count of only 10,000 this patient is not fit for interventions. Intervention should be performed with a platelet count of at least 50,000. Thus this patient got some platelets to undergo the procedure, the patient also had epistaxis and menorrhagia and thus one has to wait for these abnormal bleedings to stop before one proceeds with any intervention. The patient is ANA negative which is an expected finding in a patient with idiopathic thrombocytic purpura.

The ESR is normal telling us that the patient is not in any kind of septic state as severe sepsis also causes thrombocytopenia. One must also keep in mind that breast cancer or other cancers can also cause thrombocytopenia by infiltrating the bone marrow. ESR normal also means that one should think of something other than myloma as the cause for this or other causes that might increase the sed rate. Now there is no hepatosplenomegaly, thus thrombocytopenia is not due to problem like malaria in which chronic malaria can cause a massive splenomegaly and thus thrombocytopenia, anemia, and leukopenia. Also leukemias can present with hepatosplenomegaly thus that was an unlikely diagnosis here. Also one is being told that the urinalysis is normal which tells us that the patient is not having any hematuria. It also takes us away from the diagnosis of thrombotic thrombocytopenic purpura, DIC, and hemolytic uremic syndrome. As the treatment in those conditions is plasmaphoresis, also they tell us that the BUN and creatinine is normal thus there is no renal failure which takes us away again from the above mentioned diagnosis. Prednisone is a proper drug to start with for somebody with idiopathic thrombocytopenic purpura and it may help and as it happens in this case, the platelet count does go up and the bleeding stops. The patient can at this point get a breast biopsy but I feel that at this point it is much more safer to evaluate the patient with noninvasive methods like mammography or an ultrasound of the mass following the mammography to confirm diagnosis and to exclude any other lumps in the breasts and in mammography would one is looking for is micro calcifications which are an indication of malignancy and strong indication to go ahead and do a biopsy. If that is absent and the lump is smooth and possibly cystic, one can stear away from a biopsy and just do a close followup with this patient.

A similar question could be breast lump and patient on Warfarin whose INR is 6.9. In this case, no platelets need be given. INR can be electively allowed to drop by witholding Warfarin for a day and then starting at a lower dose. Recheck INR every 3-4 days to adjust dose. Once INR is in the therapeutic range, one can proceed with superficial surgery that has low risk of bleeding like skin surgery and superficial surgeries. If the high INR is associated with bleeding, then one quickly reverses the anticoagulation until bleeding is well controlled.