Investigations: The first laboratory tests revealed severe thrombocytopenia with a platelet count of 10,000/mm3 (the standard range is 150,000-400,000/mm3) and no abnormalities in the complete blood count. Examination of peripheral blood smears revealed platelets of average size without any indication of clumping or dysplasia. The viral serologies, coagulation profile, liver function, and renal function tests were all within normal ranges. Antinuclear antibody (ANA), rheumatoid factor (RF), and anti-dsDNA tests performed as part of an autoimmune workup came out negative. To rule out any thrombocytopenia-related reasons, a bone marrow biopsy was done.

Idiopathic thrombocytopenic purpura (ITP) was identified based on the clinical presentation, test results, and exclusion of other causes. In addition to having isolated thrombocytopenia and being free of underlying causes or other autoimmune diseases, the patient met the diagnostic criteria for ITP.

Treatment and Results: The patient was initially handled conservatively with close observation due to the lack of obvious bleeding symptoms. However, intravenous immunoglobulin (IVIG) therapy was started since the severe thrombocytopenia persisted and recurrent epistaxis developed. With an increase in platelet count to 100,000/mm3, the patient responded well to IVIG. Following discharge, she was given oral corticosteroids for maintenance medication and a follow-up appointment schedule.

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease that causes isolated thrombocytopenia via immune-mediated platelet destruction. An increased propensity to bleed, which presents as petechiae, purpura, ecchymosis, and mucocutaneous bleeding, is the defining feature of ITP [6]. However, the case of a 45-year-old female patient with ITP highlights the existence of unusual clinical presentations that create diagnostic hurdles and necessitate specialised therapy approaches. The relevance of taking into account alternate manifestations of ITP is increased by the atypical appearance of broad petechial rash throughout the extremities, oral mucosa, and conjunctivae, as well as scattered ecchymoses, in the absence of typical bleeding symptoms. This emphasises the clinical variety of the illness, needing an extensive investigation to rule out other possible causes of thrombocytopenia and a broad differential diagnosis. In this instance, thorough laboratory tests, including viral serologies, coagulopathies, and other autoimmune diseases, were carried out to exclude underlying infections, coagulation profiles, and autoimmune markers [7].

A complete blood count, which reveals isolated thrombocytopenia, and a peripheral blood smear examination, which assesses platelet morphology and rules out platelet clumping or dysplasia, are often part of the diagnostic workup for ITP. The diagnosis of ITP was supported in this instance by the peripheral blood smear, which revealed normal-sized platelets. Antinuclear antibody (ANA) and rheumatoid factor (RF), two other autoimmune indicators, were negative, confirming the lack of an underlying autoimmune illness [8]. Increasing platelet levels and lowering the risk of bleeding are the goals of ITP management plans. Observing patients with mild thrombocytopenia and minor bleeding symptoms may be appropriate rather than seeking emergency medical attention. However, intravenous immunoglobulin (IVIG) was started to offer a quick increase in platelet counts due to the persistence of severe thrombocytopenia and the emergence of recurrent epistaxis in this case. The patient responded well to IVIG, resulting in a significant platelet count rise. After that, corticosteroids were recommended as maintenance therapy [9].

It is essential to tailor the course of treatment based on the patient's features, the degree of thrombocytopenia, and the presence of bleeding signs. Immunosuppressive medications, splenectomy, and more recent targeted therapy such as thrombopoietin receptor agonists are among the various treatments available for patients with refractory or chronic ITP [10]. This case report emphasises the difficulties in diagnosing when dealing with unusual clinical presentations of ITP. To make an accurate diagnosis, it highlights the necessity for a thorough evaluation that includes a complete medical history, physical examination, and laboratory tests. To achieve positive results and avoid life-threatening consequences linked to severe thrombocytopenia in ITP, tailored care techniques based on the patient's clinical presentation and disease history are essential.

8. ITP, A., & British Committee for Standards in Haematology General Haematology Task Force. (2003). Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol, 120(1), 574-596.