Abstract / Summary
Immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterised by isolated thrombocytopenia and a variable bleeding phenotype.Patients may be asymptomatic or may present with bleeding ranging from minor skin or mucosal manifestations to uncommon, potentially life-threatening internal haemorrhage.Its occurrence with rheumatoid arthritis (RA) is uncommon, and severe disease may require treatment beyond corticosteroids and intravenous immunoglobulin (IVIG).We report the case of a 64-year-old woman with recently diagnosed seropositive RA who was found to have a platelet count of 0 x 10 9 /L after presenting with a purpuric rash and recurrent epistaxis.Haemoglobin and white cell count were preserved, and investigations did not identify an infectious, malignant, or bone marrow cause.The platelet count remained critically low despite high-dose dexamethasone, two doses of intravenous immunoglobulin (IVIG), and platelet transfusions.Romiplostim was commenced on day 6, producing a progressive platelet response.Cross-sectional imaging undertaken during the admission identified a presacral haematoma with an initially suspected pseudoaneurysm; repeat triple-phase CT showed stability without active bleeding.The patient was discharged on weekly romiplostim, and her platelet count was 197 x 10 9 /L at the 65-day postdischarge follow-up assessment.This case highlights the rare association between RA and ITP, the importance of excluding alternative causes of thrombocytopenia, and the value of early thrombopoietin receptor agonist therapy when first-line rescue treatment is unsuccessful, as well as the rare occurrence of a pre-sacral hematoma with bleeding at an unusual anatomical site as a complication of severe thrombocytopenia.