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Chemotherapy-associated hypoproliferative thrombocytopenia — ABIM Board MCQ

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HardAABBChemotherapy-associated hypoproliferative thrombocytopeniaABIM Board

A 43-year-old woman with acute myeloid leukemia is on day 12 of induction chemotherapy. She is hemodynamically stable and has no mucosal bleeding, petechiae, fever, sepsis, or disseminated intravascular coagulation. Laboratory studies show a platelet count of 16,000/mm³, hemoglobin of 8.1 g/dL, leukocyte count of 500/mm³, INR of 1.1, and aPTT of 29 seconds. Because peripheral access has repeatedly failed, she requires ultrasound-guided placement of a right internal jugular central venous catheter at a compressible site. A diagnostic lumbar puncture is also required today because flow cytometry has raised concern for central nervous system involvement by leukemia. Which of the following is the most appropriate platelet transfusion plan?

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Correct answer: B — Place the central venous catheter without prophylactic transfusion and administer platelets before lumbar puncture

Explanation lettering: E = shown as B · B = shown as C · C = shown as D · D = shown as E

The appropriate plan is to apply procedure-specific restrictive thresholds rather than a single threshold to both interventions. This patient has chemotherapy-associated hypoproliferative thrombocytopenia, no clinically significant bleeding, and a platelet count of 16,000/mm³. The 2025 AABB/ICTMG guideline recommends platelet transfusion before lumbar puncture when the platelet count is below 20,000/mm³. In contrast, for central venous catheter placement at a compressible site, transfusion is recommended only when the count is below 10,000/mm³. She therefore needs platelets for the lumbar puncture but not for the ultrasound-guided internal jugular catheter. A is incorrect because 50,000/mm³ is the recommended threshold for major nonneuraxial surgery, not these procedures. B applies the lumbar-puncture threshold unnecessarily to catheter placement. C reverses the procedure-specific thresholds: lumbar puncture carries the higher transfusion threshold. D correctly recognizes that 16,000/mm³ is above the catheter threshold but overlooks the lumbar-puncture threshold. The absence of bleeding does not eliminate the procedure-specific indication for transfusion before lumbar puncture.

Reference: Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines (May 29, 2025) — https://jamanetwork.com/journals/jama/article-abstract/2834703