Post-transfusion purpura (PTP) is a rare disease characterized by life-threatening thrombocytopenia after transfusion of any platelet-containing blood products, such as platelets(PLT) or packed red blood cells (PRBCs). We report an interesting case of PTP in a young lady after receiving multiple blood products. CASE PRESENTATION:A 36-year-old female with a past medical history of diabetes mellitus and left-sided below-knee amputation (BKA) was admitted to the Intensive Care Unit (ICU) for emphysematous osteomyelitis with intraosseous gas in the calcaneus, cuboid, and fifth metatarsal base of the right lower extremity. She underwent right-sided BKA, requiring multiple PRBC transfusions due to a combination of blood loss during surgery and chronic anemia. The initial platelet count was normal at 329,000/uL. Five days after the PRBC transfusion, it trended down to 17,000/uL and there was concurrent development of a purpuric rash over both arms. Bloodwork was notable for elevated prothrombin time and activated partial thromboplastin time. Hemolysis workup and Coombs test were negative. Fibrinogen was elevated, ruling out disseminated intravascular coagulation. PTP was suspected based on the clinical presentation and exclusion of other etiologies. Anti-human platelet antigen-1a (HPA-1a) antibodies were obtained. Empiric treatment with intravenous immunoglobulin (IVIG) and steroids was promptly initiated. Platelet count improved to 157,000/uL after four doses of IVIG. The patient tested positive for HPA-1a. However, due to the urgent need for treatment, the test sample for the anti-platelet antibodies was drawn after the initiation of IVIG. The development of thrombocytopenia in the classic time frame with the characteristic rash and improvement after receiving IVIG make PTP the most likely diagnosis. She was recommended to receive only washed PRBCs in the future to prevent a recurrence. DISCUSSION: PTP is a rare, underdiagnosed, and potentially fatal reaction, with the development of severe thrombocytopenia 2-14 days after transfusion of platelet-containing blood products. It is considered to be caused by alloimmunization against platelet antigens, with HPA-1a being the most common antibody1. Some cases of HPA-1b mediated PTP have been reported as well2. Diagnosis is often subtle and challenging, therefore a strong clinical suspicion is needed. A history of blood product transfusion a few days before the development of thrombocytopenia should make the physician think about the possibility of PTP. Treatment includes IVIG, steroids, or plasmapheresis3, and initiation of treatment should not wait for diagnostic confirmation.CONCLUSIONS: Clinicians should have high clinical suspicion for PTP in patients with acute, severe thrombocytopenia which develops after blood transfusions, and treatment should be initiated early to favorably alter the course of the disease.

A commonly seen phenomenon in the hospital and critical care setting is anaphylaxis. This acute systemic inflammatory reaction can lead to anaphylactic shock in severe cases and potentially be fatal. The role of platelets in anaphylactic reactions is not well established; however, platelets, among other mediators such as platelet-activating factor, have been shown to promote a prothrombotic state shortly after an acute hypersensitivity reaction. In addition, the aggregation of platelets promoted by platelet-activating factor and other mediators can also lead to thrombocytopenia. We present a case of a 57-year-old woman who developed severe anaphylaxis while receiving chemotherapy with paclitaxel suspended in Cremophor, a well-known allergen. She was profoundly thrombocytopenic following the reaction and was treated with therapeutic anticoagulation, with no thrombus formation.

Methods We designed and circulated a questionnaire for level 1 and 2 (ST4-5) trainees. Level 2 trainees were included in order to receive a more holistic view of both current and past training. The questionnaire was anonymous and collected by the Postgraduate training administrator at the end of regional teaching days. Results A total of 80 completed questionnaires were obtained from trainees: 8 in ST1, 21 in ST2, 13 in ST3 and 38 in ST4-5 with a response rate of 73% (80/110). Mean satisfaction rating for the quality of teaching for all three years (ST1-3) was 4.5/6. The majority of trainees had completed all paediatric training in our region (91%; n=73). Responses were concentrated on location (14%), emphasising the need for central location of teaching days within our region which is geographically large. Many trainees (37%; n=30) fed back that they would like their teaching days to be more interactive with small group sessions, cased-based discussions, practical sessions and communication scenarios. Trainees had many useful suggestions as to how regional teaching sessions could potentially be improved. We subsequently established a trainee-led teaching committee to oversee change including incorporating group sessions that promote leadership, communication and practical skills into the programme to prepare trainees to be future medical leaders. Conclusion Even when a training programme evaluates well, it is important to continuously seek trainee opinion to tailor learning, make it learner-centred and help trainees meet the curriculum requirements. The trainee-led teaching committee has already established new teaching sessions to complement the existing programme, with further sessions planned. This study reinforces the importance of engaging trainees and encouraging them to act as agents of change to improve training.

Paravathaneni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.