Open Access International Journal of Women's Health and Gynecology Volume 1 Issue 1 ISSN: 2694-4081 Case Report Idiopathic Thrombocytopenic Purpura with Inaugural Manifestation Being a Heavy Menstrual Bleeding: A Case Report Nkwabong Ea*, Tayou Cb, Borassi Sc and Banmi LNd aAssociate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences and University Teaching Hospital, Yaoundé, Cameroon bAssociate Professor, Hematologist, Department of Hematology, Faculty of Medicine and Biomedical Sciences and University Teaching Hospital, Yaoundé, Cameroon cResident, Faculty of Medicine and Biomedical Sciences, Yaoundé, Cameroon dDepartment of Obstetrics and Gynecology, Gyneco-Obstetric and Pediatric Hospital, Yaoundé, Cameroon

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Article History: Background: Abnormal uterine bleeding (AUB) is now classified using PALM-COEIN acronym. Low Received: 08 April, 2019 3 Accepted: 24 April, 2019 platelet count is a rare cause of coagulopathy in cases of AUB. With a platelet count above 30,000/mm , Published: 30 April, 2019 idiopathic thrombocytopenic purpura (ITP) is usually asymptomatic. The author hereby presents a case 3 of heavy menstrual bleeding (HMB) due to ITP with a thrombocytopenia of 37,000/mm and even * Corresponding author: Nkwabong 49,000/mm3. E, Associate Professor, Department of Obstetrics and Gynecology, Faculty of Case presentation: A 43-year-old black African woman with anaemia and thrombocytopenia was Medicine and Biomedical Sciences and referred to us for persistent menstrual bleeding despite transfusion of fresh blood. Her past history University Teaching Hospital, revealed a chronic gastric pain and no family history of coagulopathy. Seventeen days after the beginning Yaoundé, Cameroon; Tel: +(237) of HMB, she developed petechiae and bruises on the lower lip of the mouth and the left arm respectively. 699663843; Fax: +(237) 222312567; DOI: Speculum examination revealed bleeding coming from the external cervical os. The uterus was of normal https://doi.org/10.36266/IJWHG/105 size, there was no adnexal mass. Our initial diagnosis was an abnormal uterine bleeding from HMB. An urgent full blood count revealed a hemoglobin concentration of 8.5g/l, a platelet count of 49,000/mm3. She was transfused 02 pints of whole fresh blood. Due to the persistence of menstrual bleeding, a series of exploratory work-ups were done with normal results. Helicobacter Pylori (HP) was positive to urea breath test. The positive diagnosis of ITP due to HP was made. Helicobacter pylori was eradicated with Clarithromycin and omeprazole. She was successfully treated with prednisolone. The uterine bleeding stopped one week after initiation of corticosteroids. There was a biological improvement with platelet 3 count to 468,000/mm after two weeks of corticosteroid therapy. Conclusion: To the best of our knowledge, this is the first ever case of ITP due to HP with HMB as the 3 inaugural manifestation, with a platelet count above 30,000:mm . This case report also reminds us that in women who are menstruating, platelet count of 49,000/mm3 might not be enough to stop menorrhagia.

The authors recommend that ITP diagnosis should appear amongst the possible differential diagnosis in females complaining of HMB with isolated thrombocytopenia, and the initial approach should be medical treatment.

Keywords: Abnormal uterine bleeding; Corticosteroid; Heavy menstrual bleeding; Helicobacter pylori; Immune thrombocytopenic purpura

Copyright: © 2019 Nkwabong E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

purpura or not. More often, there are no obvious initiating and/or Background underlying causes of the thrombocytopenia. When Abnormal uterine bleeding (AUB) is now classified using PALM- thrombocytopenia is severe (<30,000/mm3), ITP clinically COEIN acronym [1]. Coagulopathy is an infrequent cause of manifests with hemorrhage such as petechiae, bruising, epistaxis AUB, especially in women with a normal anatomy, though low or spontaneous gingival bleeding [3]. Above 30,000/mm3, it is platelet count can be a cause, as seen in idiopathic usually asymptomatic [4]. The authors hereby report a case of ITP thrombocytopenic purpura (ITP). Primary ITP is defined in a 43-year-old black African woman with a thrombocytopenia of according to the American Society of Hematology 2011 evidence- 37,000/mm3 initiating a heavy menstrual bleeding (HMB). based practice guideline as a platelet count less than 100 × 109/L Case Presentation without other causes or disorders that may be associated with thrombocytopenia [2]. ITP might be associated with hemorrhagic A 43-year-old black African woman, G8P8007 consulted in

Pubtexto Publishers | www.pubtexto.com 1 Int J Womens Health Gynecol Citation: Nkwabong E, Tayou C, Borassi S, Banmi LN (2019). Idiopathic Thrombocytopenic Purpura with Inaugural Manifestation Being a Heavy Menstrual Bleeding: A Case Report. Int J Womens Health Gynecol 1(1): 105 DOI: https://doi.org/10.36266/IJWHG/105

November 2018 in a regional hospital for HMB that started 19 inflammatory drugs, antibiotics, anticonvulsant, heparin). ITP can days ago. A full blood count at that time revealed a hemoglobin also result from dysthyroidism and immunological diseases. The concentration of 4.2 g/dl and thrombocytopenia of 37,000/mm3. central causes can be constitutional or due to some hematological The white blood cell count was 9,900/mm3. Due to the lack of diseases. In our patient, ITP was induced by an infection by platelet concentrates, she was transfused with two pints of whole Helicobacter pylori, as already observed by another researcher [7]. blood only, which yielded a slight reduction of the quantity of More often, ITP is asymptomatic, the low platelets being menstrual bleeding. Two days before referral to us, she presented discovered fortuitously. When the platelet count is below with epistaxis, gingival bleeding and exacerbation of HMB. A 30,000/mm3, coagulation is abnormal and bleeding may occur second hemogram showed a hemoglobin concentration of 7.2 g/dl spontaneously in the form of bruising or petechiae. Bleeding can and thrombocytopenia of 67,000/mm3. The white blood cell count also affect mucous membranes, causing gingival bleeding or was 7,200/mm3. She received a third pint of whole fresh blood. epistaxis. Our patient had oral petechia, though initial platelet The persistence of menstrual bleeding motivated the reference to count was above 30,000/mm3. This case report shows that in our unit. She had a past history of chronic epigastric pain without women who are menstruating, platelet count even above any family or personal history of HMB. Clinical examination 45,000/mm3 might not be enough to stop menorrhagia. More carried out at admission revealed a temperature of 37.2°C, a blood serious bleeding at the level of the brain and intestines are possible pressure of 116/72 mm Hg with a pulse rate of 110/min. The if the number of platelets is very low [6]. Also, a case of conjunctivae were pale. Petechiae were found on the lower lip of hemoperitoneum following ovulation has been recently observed the mouth as well as bruises on the left arm. Speculum [8]. ITP can be diagnosed with the detection of anti-platelet examination revealed bleeding coming out from the external autoantibodies. This test has a high specificity but a low sensitivity cervical os. Digital vaginal examination showed a closed cervix, [9]. In our environment no laboratory can perform this test. ITP is the size of the uterus was normal, and no adnexal mass was felt. suspected in case of isolated thrombocytopenia less than Our initial diagnosis was an AUB due to a coagulation disorder. 100,000/mm3 without other causes or disorders that may be An urgent hemogram showed a hemoglobin of 8.5g/l, platelet associated with thrombocytopenia [2], as in our patient. Regarding count of 49,000/mm3. A standard ultrasound scan revealed no its mode of evolution, there are three forms: acute (duration of abnormalities. A series of exploratory work-ups were requested. evolution <3 months), persistent (duration of evolution between 3 The HIV, chlamydia, hepatitis B and C tests were all negative. and 12 months) and chronic (duration of evolution> 12 months) Helicobacter Pylori (HP) was positive to urea breath test. The [10]. The evolution in the adult is most often chronic in 2/3 of the positive diagnosis of ITP due to HP was made. She received cases. Evolution is then unpredictable with periods of remission prednisolone tablet (Cortancyl®) 120 mg intravenously twice or relapse. The different treatment modalities may include daily for 3 days, followed by oral route 40 mg thrice daily for 2 corticosteroids, intravenous polyvalent immunoglobulins (IVIg), days, then 20 mg thrice daily for 10 days. From the 16th day the splenectomy or even therapeutic abstention [11, 12]. Platelet dose was reduced to 20 mg daily. Helicobacter pylori was growth factors such as eltrombopag and romiplostim have been eradicated after two weeks treatment with clarithromycin (500 mg successfully used for treating ITP [13]. Therapeutic abstention is thrice daily) and omeprazole (40 mg daily). The uterine bleeding indicated in asymptomatic patients with a platelet count > stopped just one week after initiation of corticosteroids. Two 50,000/mm3 [7]. Nevertheless, patients with platelet counts weeks after treatment, there was a biological improvement with a <50,000/mm3 and/or hemorrhagic syndrome can receive IVIg or platelet count of 468,000/mm3. The patient continued corticosteroids, as our patient. Corticosteroid therapy remains the corticosteroids for three months. She presented no other episodes first-line therapy with a response rate of 54%. Nevertheless, the of HMB. relapse rate can go up to 86% [7]. Splenectomy is the standard treatment for chronic ITP [12], but it renders patients more Discussion vulnerable to infections [14]. In cases of failure of treatment of ITP is a rare disease, with an estimated incidence of 3 to 4 per chronic ITP, androgens (danazol), immunomodulators (dapsone, 100,000 inhabitants /year with a slight female predominance [2], ciclosporin), immunosuppressors (azathioprine, as in our case. It is also found in 1 in every 1000-10,000 cyclophosphamide) and innovative therapeutics such as pregnancies [5]. ITP is due to platelets destruction mediated by humanized monoclonal antibodies (anti-CD20, anti-CD52 or anti- antibodies directed against the surface of the platelets [6], with CD154), hematopoietic growth factors (recombinant their subsequent destruction by the reticuloendothelial system, thrombopoietin) and bone marrow transplants [7] can be offered. particularly the spleen. ITP can also result from a reduction in the The eradication of Helicobacter pylori when present is also production of platelets by the bone marrow. The initiating causes recommended [15], as in our patient, as this eradication is of ITP may be peripheral (by destruction and/or excessive associated with positive outcome in 50% of cases. consumption of platelets) or central (by insufficient platelet Conclusion production) [7]. Peripheral causes include infections (mainly HIV, hepatitis B and C, Epstein Barr Virus, Cytomegalovirus, ITP is a rare disease that manifests itself by a hemorrhagic Helicobacter pylori, malaria, sepsis), drugs (non-steroidal anti- syndrome. Spontaneous bleeding is said to be absent when the Pubtexto Publishers | www.pubtexto.com 2 Int J Womens Health Gynecol

Citation: Nkwabong E, Tayou C, Borassi S, Banmi LN (2019). Idiopathic Thrombocytopenic Purpura with Inaugural Manifestation Being a Heavy Menstrual Bleeding: A Case Report. Int J Womens Health Gynecol 1(1): 105 DOI: https://doi.org/10.36266/IJWHG/105 platelet count is above 30,000/mm3. This case report shows that it 3. Dunphy L, Williams R. Immune thrombocytopenic purpura is not always true, especially in women menstruating. This case presenting with spontaneous gingival haemorrhage in pregnancy. report also reminds us that in women who are menstruating, BMJ Case Rep. 2019; 12. platelet count even above 45,000/mm3 might not be enough to 4. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM et al. Standardization of terminology, definitions and outcome stop menorrhagia. The authors recommend that physicians should criteria in immune thrombocytopenic purpura of adults and think about ITP when HMB is associated with isolated children: report from an international working group. Blood. 2009; thrombocytopenia, and the initial approach should be medical 113: 2386-2393. treatment. 5. Al-Husban N, Al-Kuran O. Post-Partum Thrombotic Thrombocytopenic Purpura TTP in a Patient with known Idiopathic List of Abbreviations (Immune) Thrombocytopenic Purpura: a case report and review of AUB: Abnormal Uterine Bleeding; HIV: Human the literature. J Med Case Rep. 2018; 12: 147. Immunodeficiency Virus; HMB: Heavy Menstrual Bleeding; HP: 6. García-Stivalet LA, Muñoz-Flores A, Montiel-Jarquín AJ, Barragán-Hervella RG, Bejarano-Huertas R, García-Carrasco M, Helicobacter Pylori; ITP: Idiopathic (Or Immune) López-Colombo A. Clinical analysis of 200 cases of idiopathic Thrombocytopenic Purpura; IVIG: Intravenous Polyvalent thrombocytopenic purpura Article in Spanish. Rev Med Inst Mex Immunoglobulins; PALM-COEIN: Polyp, Adenomyosis, Seguro Soc. 2014; 52: 322-325. Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, 7. Provan D, Newland A. Fifty years of idiopathic thrombocytopenic Ovulatory Disorders, Endometrial Dysfunction, Iatrogenic, Not purpura ITP management of refractory ITP in adults. Br J Haematol. Yet Classified 2002; 118 : 933-44. 8. Buskmiller C, Rosenberg H, Sen S. Hemoperitoneum after ovulation Consent for publication in systemic lupus erythematosus and autoimmune thrombocytopenia. Case Rep Obstet Gynecol. 2019; 1-4. Written informed consent was obtained from the patient for 9. Kelton JG, Vrbensky JR, Arnold DM. How do we diagnose immune publication of this case report and any accompanying images. A thrombocytopenia in 2018? Hematology Am Soc Hematol Educ copy of the written consent is available for review by the Editor- Program. 2018; 1: 561-567. in-Chief of this journal. 10. Damian L, Jardin F, Langlois V, Kerleau JM, Benhamou Y, Levesque H, et al. Thrombopenie immunologique primaire de Acknowledgements l’adulte : facteurs prédictifs d’évolution vers la chronicite. Rev Med Not applicable; Funding: Not applicable; Availability of data and Int. 2018; 39: 36‑37. 11. Reynolds SB, Hashmi H, Ngo P, Kloecker G. Rescue therapy for materials: Not applicable; Author’s contribution: EN & SB acute idiopathic thrombocytopenic purpura unresponsive to managed the case and wrote the case report, CT also managed the conventional treatment. BMJ Case Rep. 2019; 12. case, LNB reviewed the article critically. All the authors approved 12. Kajimura Y, Tanaka Y, Nohno S, Tanaka M, Nakamura Y, Yujiri T, the final manuscript. et al. Refractory primary immune thrombocytopenia in pregnancy Competing interests requiring splenectomy and repeated intravenous immunoglobulin therapy Article in Japanese. Rinsho Ketsueki. 2018; 59: 2574-2577. The authors declare that they have no competing interests; Ethics 13. Zhang J, Liang Y, Ai Y, Li X, Xie J. Eltrombopag versus approval and consent to participate: Not applicable. romiplostim in treatment of adult patients with immune thrombocytopenia: a systematic review incorporating an indirect- References comparison meta-analysis. PLoS One. 2018. 14. Kang CM, Lee JG, Kim KS, Choi JS, Lee WJ, Kim BR, et al. Long- 1. Munro MG, Critchley HOD, Fraser IS. The Flexible FIGO term follow-up of laparoscopic splenectomy in patients with immune Classification Concept for Underlying Causes of Abnormal Uterine thrombocytopenic purpura. J Korean Med Sci. 2007; 22: 420-424. Bleeding. Semin Reprod Med. 2011; 29: 391-399. 15. Jackson S, Beck PL, Pineo GF, Poon MC. Helicobacter pylori 2. Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther eradication: novel therapy for immune thrombocytopenic purpura? MA. The American Society of Hematology 2011 evidence-based A review of the literature. Am J Hematol. 2005; 78: 142-50. practice guideline for immune thrombocytopenia. Blood. 2011; 117: 4190-4207.

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