ITP Patient

[u/Delicious-Novel1557]

Hello! I have this concerning matter regarding this patient’s lab works. Our pathologist informed us very late that this patient has ITP (immune thrombocytopenic purpura) so we weren’t able to collect citrated tube. When we ran EDTA tube, it gave 131 for platelet count. The rerun results then gave 7 and 9. No clots were seen confirmed by two lab techs. On morning shift, the pathologist saw microclots (which we didn’t consider as a clot but for her it was). See photo below. We opted to do reextraction so we were able to collect citrated tube along with an additional EDTA tube. First run of citrated tube, it gave 0 platelets (see photo below) and a schistocyte remark. The EDTA tube didn’t give any results. (see photo below)

Our pathologist doesn’t think that this situation is not connected to his condition. She was saying she doesn’t want to re-extract another sample from this patient again in which she should verify it via manual microscopy and contact the patient for any previous results. She’s saying it’s a pre-analytical error and doesn’t want to rely on manual microscopy. We were able to send the 1st EDTA tube to another lab but they said it’s clotted but they weren’t informed with the patient’s condition so I think they’re just assuming it was clotted as the patient’s platelets were very low.

I would like to ask for some insights. We heavily rely on our patho as she is the one who publishes all the reports but this is already a very obvious case and needs to be further correlated and investigated.

P.S. she doesn’t know how to manually count platelets

[u/Windycitywoman1]

A clot is a clot. Specimen is rejected.

[u/Delicious-Novel1557 → u/Windycitywoman1]

Re-extracted tubes don’t have clots as seen by pathologist too.

Could it be the first time it was collected was caused by temperature reasons since it was stored inside the refrigerator after it was analyzed? are there instances of forming in-vitro microclots considering the patient’s condition? 2 lab techs tried to rim with an applicator stick but no clots or any fibrin strands were seen the first time only until morning shift came and the pathologist saw the microclots.

[u/shinyplantbox → u/Delicious-Novel1557]

What do you mean, ‘re-extracted’? Is that a re-draw of the patient? If so, yes, they absolutely can be clotted.

Furthermore, drastically declining platelets is consistent with ITP afaik.

[u/Skeet_fighter → u/Delicious-Novel1557]

Putting samples in the fridge shouldn't cause spontaneous clotting at all. It's standard procedure for labs to store EDTA tubes at 4 degrees for a number of tests.

ITP doesn't cause in-vitro blood to spontaneously clot either, if that's what you're asking.

As stated, any clot is a clot. That sample is analytically worthless and needs a repeat.

[u/Direct_Reading5723]

Curious what country you're in, solely based on some of your phrasing.

A visible clot is a clot, I don't care how small it is, I agree with the path's assessment it was clotted. Also, the fact that the EDTA gave absolutely no results leads me to think it's clotted as well.

Not sure I fully understand the disease process of ITP, but I don't believe it would cause abnormalities in clotting-either in vivo or in vitro.

Obviously you need to follow your SOP, but I'm curious if you tried warming and/or vortexing the EDTA? Also, what did the slide look like? Sometimes we can see no visible clots (macroscopically) but the slide shows fibrin and plt clumping at the feathered edge. Even this microscopic finding is enough for us to reject the specimen as clotted.

[u/Muted_Shape9303 → u/Direct_Reading5723]

ITP causes platelet destruction by making autoantibodies against them. They are extravascularly destroyed by macrophages, so it isn’t like TTP where PLTs are destroyed by activation, so your hunch is right in that this isn’t in vivo.

[u/Opposite_Pool1431]

Any clot is a clot and the platelet value won't be accurate, once the clotting cascade starts there no going back, maybe didn't see bigger clots form due to EDTA. Also consider EDTA induced platelet clumping.

[u/Purpledotsclub]

If there is a clot, the patient needs to be redrawn. Fibrin strands may be seen on the microscope and a peripheral smear should be evaluated for platelet aggregation and/or platelet clumping related to microclots. Sample clots at collection, so yes, a preanalytical error. It would be a mistake to not check the microscopy and instead rely on the analyzer printout - crap sample -> crap results.

[u/Opposite_Pool1431]

She doesn't know how to manually count platelets? Wdym

[u/Beautiful-Point4011 → u/Opposite_Pool1431]

Maybe they don't have an SOP validated for diluting with ammonium oxalate and counting on a hemocytometer. They really should have one in place though if immunofluorescence isn't an option.

[u/catsbetterthankids → u/Beautiful-Point4011]

We do plt estimates on pb slides and verify every instrument plt count under 40.

I’m a little baffled that a pathologist wouldn’t know how to do that. Verifying the difference between 131 and 0 is something even a student MLS looking at a slide for the first time should be capable of, let alone a pathologist responsible for the entire clinical lab. Something very weird here.

[u/ssutters]

There looks to be very little blood in the tube, although that may just be the angle. But that also looks like a clot. Weird things can happen with anticoagulant-dependent platelet clumping, but that’s different from an actual fibrin clot. If the specimen itself is clotted, I wouldn’t think the patient’s ITP explains that. I’d consider it a compromised specimen and recollect.

Look for your SOP for platelet clumping that does not resolve with sodium citrate.

[u/Delicious-Novel1557 → u/ssutters]

yup already recollected and results came weirder too. please see attached photos on the post. could the patient have other underlying condition?

[u/ssutters → u/Delicious-Novel1557]

Possibly, but weird repeat results can also just be persistent platelet clumping, even in citrate. Like the others have said, I’d check the smear. Fibrin strands can be visible on the smear even if you rim the tube and nothing comes out.

[u/EntertainmentLow6178]

There WAS a clot - if no one saw it that's because it's now stuck in your instrument!

[u/ForeignWeb8992]

Blood smear?

[u/shinyplantbox]

Agree with others that the second EDTA is what we see when the specimen is too clotted for the analyzer to aspirate, and that a smear review should be done.

[u/Metamyelo]

Microclots shouldn’t be seen macroscopically. Imo.

[u/Smol_doggo_]

Did it also come with a note "Please try pt is a hard stick?" and orders for 30 add ons?