A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 19-year-old girl with a history of immune thrombocytopenic purpura (ITP), managed with systemic corticosteroids, presents with bruising, acne, and weight gain. Patient says that 3 months ago she gradually began to notice significant weight gain and facial and truncal acne. She says these symptoms progressively worsened until she discontinued her corticosteroid therapy 4 weeks ago. This week, she began to notice multiple bruises all over her body. Past medical history is significant for ITP, diagnosed 11 years ago, managed until recently with systemic corticosteroid therapy. The patient is afebrile and vital signs are within normal limits. On physical examination, there are multiple petechiae and superficial bruises on her torso and extremities bilaterally. There is moderate truncal obesity and as well as a mild posterior cervical adipose deposition. Multiple deep comedones are present on the face and upper torso. Which of the following is the best course of treatment in this patient?
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A
Administration of intravenous immunoglobulinIncorrect. IVIG provides rapid but transient platelet rise (days to weeks) for acute bleeding or before procedures - it is not the appropriate long-term treatment for chronic steroid-dependent ITP.
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B
Continuation of systemic corticosteroid therapyIncorrect. Continuing corticosteroids would worsen her already florid iatrogenic Cushing syndrome and is contraindicated.
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C
SplenectomyCorrect. Splenectomy is a classic second-line therapy for chronic, steroid-refractory or steroid-dependent ITP and offers durable remission in roughly two-thirds of patients.
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D
Transfusion of thrombocytesIncorrect. Platelet transfusion is reserved for life-threatening bleeding; in ITP, transfused platelets are quickly destroyed by the same autoantibodies and offer no durable benefit.
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E
Rituximab infusionIncorrect. Rituximab is an effective second-line agent for chronic ITP and is sometimes used to defer splenectomy, but the classic durable second-line therapy with the highest long-term remission rate is splenectomy.
↑ Tap an answer to reveal the reasoning
Answer: C. A young patient with longstanding ITP has been on chronic systemic corticosteroids for 11 years and now shows clear-cut iatrogenic Cushing syndrome: truncal obesity, posterior cervical fat pad ('buffalo hump'), facial/truncal acne, and recently bruising consistent with steroid-induced thin skin and capillary fragility. She self-discontinued steroids 4 weeks ago, and her platelet count has now dropped (petechiae, bruising), reflecting recurrent thrombocytopenia.
For adults with chronic, steroid-refractory or steroid-dependent ITP (defined as needing unacceptable steroid doses to maintain platelets, or relapsing when steroids are withdrawn), second-line therapy is splenectomy or, in modern practice, thrombopoietin-receptor agonists (romiplostim, eltrombopag) or rituximab. In USMLE-style questions, splenectomy is the classic second-line answer because it removes the major site of antibody-coated platelet destruction and offers a durable response in ~60-70% of patients. After splenectomy, vaccination against encapsulated organisms (S. pneumoniae, H. influenzae, N. meningitidis) is required.
IV immunoglobulin is for acute, severe bleeding or rapid platelet rise before procedures - it does not provide durable disease control. Continuing corticosteroids is wrong because they have already caused frank Cushing syndrome. Platelet transfusion is reserved for life-threatening bleeding because transfused platelets are rapidly destroyed by the same autoantibodies.
**Why each option:**
**A.** IVIG provides rapid but transient platelet rise (days to weeks) for acute bleeding or before procedures - it is not the appropriate long-term treatment for chronic steroid-dependent ITP.
**B.** Continuing corticosteroids would worsen her already florid iatrogenic Cushing syndrome and is contraindicated.
**C.** Correct. Splenectomy is a classic second-line therapy for chronic, steroid-refractory or steroid-dependent ITP and offers durable remission in roughly two-thirds of patients.
**D.** Platelet transfusion is reserved for life-threatening bleeding; in ITP, transfused platelets are quickly destroyed by the same autoantibodies and offer no durable benefit.