Dr. Roach: Bleeding disease requires hematologist care

Dear Dr. Roach: My brother is 71 and is having a very difficult time with an extremely low blood platelet count (20). He was supposed to have surgery, but cannot because of this issue. Doctors cannot seem to find a cause or manage it well. He has been in and out of hospitals for three months and is tested every week. The only thing that seems to help temporarily is prednisone, although he is having difficulty with the side effects — his count comes within the normal range after a while on it, but slips back down when he is off it. What do you know of this disease? He is afraid to leave home, as he could easily “bleed out” if in an accident, etc. Is there anything that canhelp him?

J.P.

Dear J.P.: It sounds like your brother has idiopathic thrombocytopenic purpura, an autoimmune disease in which the body destroys its own platelets, the specialized cells responsible for immediate stopping of bleeding. ITP is fairly common, although many people don’t realize they have it, as many cases are very mild and don’t include significant bleeding. ITP also can cause petechiae, flat red patches of bleeding in the skin that can coalesce to form the purpura of its name. When it happens in the mucus membranes in the mouth, it predicts a more severe course than on dry skin.

In your brother’s case, ITP is more serious. Nosebleeds and serious bleeding, including inside the brain, are uncommon but can happen with very low platelet counts, below 20 (we mean 20,000 when we say “20”).

The steroid prednisone is effective in the short term at raising platelets, but it causes so many complications that we think twice before using it long term. Immunoglobulin also is used for short-term treatment, such as when surgery is needed.

Long-term treatments include removing the spleen and using medications such as rituximab (Rituxin). His hematologist will be the one to recommend long-term therapy if necessary (which it sounds like it may be). Possibly, the hematologist is waiting to see whether the platelet count will finally have a prolonged response to the prednisone.

Dear Dr. Roach: I am a man in my late 80s. I expect my primary care doctor to check the following: carotid arteries, peripheral artery disease, blood analysis, urine analysis and the possibility of Parkinson’s. Is this asking too much?

R.

Dear R: It’s not asking too much. Your requests are modest and are relatively inexpensive. The doctor can listen to your carotid arteries with a stethoscope for a rough estimation of their health. More-expensive tests would be done if you had any symptoms that aroused suspicion that those arteries might be obstructed.

Email questions to ToYourGoodHealth@med.cornell.edu.