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H pylori-associated immune thrombocytopenia — ABIM Board MCQ

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HardHelicobacter pyloriH pylori-associated immune thrombocytopeniaABIM Board

A 38-year-old woman is evaluated for incidentally discovered thrombocytopenia. She has occasional petechiae but no mucosal bleeding, menorrhagia, or gastrointestinal bleeding. Her platelet count is 46,000/μL; hemoglobin and leukocyte counts are normal. Peripheral smear shows reduced platelets with occasional large forms and no schistocytes or dysplasia. Liver tests, creatinine, prothrombin time, and partial thromboplastin time are normal. HIV and hepatitis C testing are negative. She takes no medications, does not drink alcohol, and has no splenomegaly. Because of intermittent epigastric discomfort and previous residence in a region with high Helicobacter pylori prevalence, a urea breath test is obtained and is positive. She has never received H pylori eradication therapy and is not scheduled for an invasive procedure. Which of the following is the best initial management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Initiate H pylori eradication therapy with platelet observation

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

This patient has immune thrombocytopenia: thrombocytopenia is isolated, the smear lacks schistocytes or dysplasia, coagulation and liver studies are normal, and important secondary causes have been excluded. However, her platelet count is above 30,000/μL, bleeding is limited to minor cutaneous findings, and she has no anticoagulant use, upcoming procedure, advanced age, or other factor that would favor immediate platelet-directed therapy. Observation rather than corticosteroids is therefore appropriate for the thrombocytopenia itself. The positive urea breath test demonstrates active H pylori infection. US hematology guidance recommends eradication therapy when H pylori is identified in a patient with immune thrombocytopenia; successful eradication can produce a platelet response in a subset of patients. Thus, eradication should not be deferred merely because corticosteroids are unnecessary. A omits indicated treatment of active infection. B both leaves H pylori untreated and exposes the patient to unnecessary corticosteroid toxicity. C is reserved for clinically important bleeding or circumstances requiring a rapid platelet increase. D appropriately treats H pylori but adds corticosteroids despite a platelet count and bleeding phenotype favoring observation. Platelet counts should be followed after eradication, with ITP-directed treatment added if significant bleeding develops or the count falls below the treatment threshold.

Reference: American Society of Hematology 2019 guidelines for immune thrombocytopenia (2019) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6963252/ The 2022 review of the 2019 American Society of Hematology guidelines on immune thrombocytopenia (2024) — https://pubmed.ncbi.nlm.nih.gov/38608258/