Chronic Sinusitis and a
History of Immune Thrombocytopenia
Bret R. Haymore, MD
Walter Reed Army Medical Center
Mar 2007
History
• 59 y/o Caucasian female
• Referred by PCM for ‘chronic allergies’
• Began ~10yrs prior
• Biggest complaint is non productive cough
• Colds ‘that won’t go away’
– subsequent sinus pressure, abx given ~1x/yr
• No other recurrent infections
Medical History
PMHx:
Immune thrombocytopenic
purpura- May 2005
Chronic rhinitis/cough
Recurrent sinusitis
Shingles 2003
Mitral valve prolapse
PSHx:
Splenectomy Oct 2005
SH:
Married, 2 Children
No tobacco use
Dog in home
Wood-burning stove
FH:
No atopic/autoimmune hx
No consanguinity
Immunization hx:
pneumococcal,
meningococcal & Hib
• Medications
– cetirizine
– montelukast
– nasal fluticasone
– nasal atrovent
– saline spray prn
– atenolol
– ibuprofen prn
– acetaminophen prn
– glucosamine/chondroitin
Medical History Cont’d
• Drug allergies:
sulfonamides
(urticaria 2001)
ROS
• Gen: no fever/chills/constitutional symptoms
• HEENT: no eye, ear complaints
no sneezing or nasal/ocular pruritus
• Resp: no dyspnea, wheezing
• CV: no cardiac complaints
• GI: no N/V/diarrhea, constipation
• Skin: no rashes/lesions
• MSK: arthralgias since Jan2005
loosens up in few minutes
More on Her ITP
• May 2005- given amoxicillin for sinusitis
• 2 wks later noted petechiae
• PCM visit, platelets of <3,000/µl
• Hospitalized & diagnosed w/ ITP
• Extensive treatment regimen
• Splenectomy Oct 2005
• Platelet counts normal since Dec 2005
Platelet Count vs. Time
400,000
350,000
300,000
250,000
200,000
150,000
50,000
100,000
Ma
y 2
00
5
Jun
20
05
Jul
20
05
Au
g 2
005
Se
p 2
005
Oc
t 2
00
5
No
v 2
005
De
c 2
00
5
Jul
20
06
100
80
60
40
20
Anti-D
Rituximab
IVIG
Azathioprine
Splenectomy
Prednisone
IVIG
Physical Exam
• VSS, WD/WN
• HEENT- mild pharyngeal inflammation
isolated anterior cervical node, 1cm & mobile
• CV- wnl
• Lungs- CTA B/L
• Abd- absent spleen tip
• Skin- no lesions/rashes
• MSK- Heberden nodules, no synovitis
Initial Laboratory Evaluation