Steroid-Resistant Immune Thrombocytopenia With Severe Bleeding Successfully Managed Using Eltrombopag and Mycophenolate in a 67-Year-Old Male

TL;DR

An elderly man with severe, steroid-resistant immune thrombocytopenia was successfully treated with a combination of eltrombopag and mycophenolate.

Contribution

Demonstrates successful management of steroid-refractory ITP using a combination of eltrombopag and mycophenolate in an older adult.

Findings

Platelet count normalized within two weeks after starting mycophenolate and eltrombopag.

Combination therapy resolved severe bleeding and steroid-resistant thrombocytopenia.

Highlights the potential of combining TPO-RAs with immunosuppressive agents in refractory ITP cases.

Abstract

A 67-year-old man presented with severe mucocutaneous bleeding and profound thrombocytopenia with a platelet count of 6 × 10³ per microliter. Bone marrow examination showed preserved megakaryocytes, and secondary causes were excluded, confirming primary immune thrombocytopenia (ITP). Despite high-dose intravenous methylprednisolone followed by oral corticosteroids, platelet count remained 8 × 10³ per microliter. Two weeks after the presentation, azathioprine was initiated due to persistent severe thrombocytopenia, and eltrombopag was added. Response remained minimal. One month after the presentation, he was classified as having steroid-refractory disease. Azathioprine was discontinued, and mycophenolate mofetil was started. Platelet count rose steadily, reaching 88 × 10³ per microliter at discharge and normalizing to more than 150 × 10³ per microliter within two weeks, with complete resolution of bleeding. This case highlights the diagnostic challenges of ITP in older adults and supports combining thrombopoietin receptor agonists (TPO-RAs) with targeted immunosuppressive therapy in steroid-refractory disease.

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