FRCPath Haem Part 1 MCQs-Transfusion 458

A 69-year-old multiparous woman is admitted with melaena and symptomatic anaemia. She receives 3 units of red cells for a bleeding gastric ulcer. Eight days later she develops widespread purpura, epistaxis, gum bleeding and new haematuria.

Investigations show:

• Hb 88 g/L

• WBC 6.9 × 10⁹/L

• Platelets 2 × 10⁹/L (previously 245 × 10⁹/L)

• PT 12 s, APTT 30 s, fibrinogen 3.8 g/L

• Blood film: severe thrombocytopenia without schistocytes

She receives: IVIg 2 g/kg over 2 days and Tranexamic acid.

Five days later: Platelets remain 3 × 10⁹/L . Ongoing epistaxis requiring nasal packing . No evidence of DIC, TTP, HIT or drug-induced thrombocytopenia.

What is the MOST appropriate next step in management?

A. Repeat random donor platelet transfusions every 12 hours until platelet recovery

B. Start high-dose corticosteroids alone and observe for another 5–7 days

C. Commence urgent therapeutic plasma exchange while continuing supportive care

D. Perform emergency splenectomy because IVIg has failed

E. Begin romiplostim to stimulate platelet production