An elderly man with intraoral lesions and generalized weakness....

An elderly gentleman is sent to the emergency department by his primary care physician.  He complains of dark intraoral lesions that appear and disappear for the last 2-3 days.  He also complained of generalized weakness and dark, foul-smelling stools.

What is on your differential diagnosis?  Diagnostic workup? .   

(Scroll down for Case Conclusion)

Diagnosis: Idiopathic Thrombocytopenic Purpura (ITP)

Case Conclusion: 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 due to an ongoing upper GI bleed:

Learning Point: The intra-oral purpuric lesion seen in this patient is most commonly known as “wet purpura” (also has hemorrhagic bullae).  Hemorrhagic bullae are a clinical exam finding associated with ITP.  While  “dry-purpura” such as bruising and petechiae are indicative of having 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 [1,3].  In one small study aimed at developing a bleeding risk score for patients with ITP, they found a highly significant correlation between wet purpura and overall risk of intracranial hemorrhage (P = 0.009 for wet purpura on physical exam ; P = 0.014 for hx of wet purpura) [2].  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 [3]. 

(Case Conclusion by Maia Dorsett, PGY-4)

References:

1.Crosby, W. H. (1975). Wet purpura, dry purpura. Jama, 232(7), 744-745.

2.Page, L. K., Psaila, B., Provan, D., Michael Hamilton, J., Jenkins, J. M., Elish, A. S., ... & Bussel, J. B. (2007). The immune thrombocytopenic purpura (ITP) bleeding score: assessment of bleeding in patients with ITP. British journal of haematology, 138(2), 245-248.

3. Kistangari, G., & McCrae, K. R. (2013). Immune thrombocytopenia. Hematology/oncology clinics of North America, 27(3), 495-520.