Sometimes a hematoma is just a hematoma

O boy I had a scare this morning.

As I posted elsewhere, one day in late Sept I awoke with 3-4 hemotomas - blood blisters- in my mouth. This was the beginning of a good 6 week experience with near -zero platelets, 4 trips to the hospital (one 9 days long) and finally, a late response to several weekly Nplate injections that we used to safer surgery for a splenectomy. After the surgery my numbers were in the 600 and dropped every week by about 100 until they plateaued in the mid 200s. I've been tapering down on prednisone- down to 15 mg this week.

A week ago today my Dr. and I decided to wait 2 weeks for the next bloodwork. So this morning I awakened with the faint taste of blood and a hematoma on my left inner cheek. (Except for that week in Sept I never noticed any before in my life) O boy, I think, that's it... my numbers are dropping. I guess I'll need Nplate injections...

But my platelets were at 330. And this evening the hematoma is gone.

Mark

If you are at 330, why do another injection? Who knows the cause of the hematoma in your mouth. Possible you bit your cheek or just a weak vessel.

Sorry - I think I didn't explain well enough. I had never experienced a hematoma like that except for the morning in Sept that was the first day of a month and a half of single digit platelets that eventually led to my splenectomy. So I was sure the other day that my numbers had dropped again - and my only recourse would be Nplate injections.

So I went to get the them checked. I was happily proved wrong and my number was 330. Hence, the title of my post.

that is really great news, I bet you were so happy! I've had bruises when counts were higher and nothing with low counts- doesn't always make sense except that there are a lot of factors involved not just platelets.

Understood.

What other factors are involved? I usually have several bruises when platelets are low. However, a couple days ago my platelets were 6. I don't have any bruises and feel o.k.
I've had numerous IVIGs and decided to wait another week before having IVIG.
I've never tried Nplates and may have to do something different than constant IVIGs.

I don't know all the factors involved in spontaneous bruising when platelets are low. But what has been explained to me about blood clotting is that blood clotting is a "cascading effect" of many different body chemicals and proteins. Platelets are the first line of defense, but there are other body chemicals that come in right behind platelets to do the job.

Some people do bleed with low platelet counts so I feel lucky that my body is compensating. I've never had a problem with bleeding even at 6K. But when my counts are below 30K I stay off the freeways and take it easy. Not suggesting that anyone ignore low counts but I've gotten to know my body and know that its okay.

Here is a brief explanation from Wikipedia:

Coagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel.

Coagulation begins almost instantly after an injury to the blood vessel has damaged the endothelium lining the vessel. Exposure of the blood to proteins such as tissue factor initiates changes to blood platelets and the plasma protein fibrinogen, a clotting factor. Platelets immediately form a plug at the site of injury; this is called primary hemostasis. Secondary hemostasis occurs simultaneously: Proteins in the blood plasma, called coagulation factors or clotting factors, respond in a complex cascade to form fibrin strands, which strengthen the platelet plug.

Mark, I know what you mean and have found also that I now sometimes have blood blisters at high counts. When I thought about it I realised that in the past if I felt something in my cheek I'd touch it with my tongue and then ignore it whereas now I look. Had I looked before I'd probably have found a blood blister but I just never did. So I probably don't get more blood blisters now than before, I just never knew about them.

Hi

Since posting this I think I know why I had the hematoma – I had a temporary dental cap placed on my right side. The permanent one isn’t ready yet – and the temp has come off twice, yet to be replaced. After two replacement I have finally been making more of an effort to chew on my left side- where the hematoma occurred. So I think some food- probably a pretzel scratched my inner cheek. I feel a little silly and embarrassed, but … I think I still would have gotten my numbers checked that day even if I had thought of this.

Poseymint – you wrote “I bet you were so happy!” – which made me reflect. Certainly when my platelet numbers rose in late October, allowing me to get safer surgery, it was very exhilarating - because I had been in crisis for weeks, not knowing if my numbers were going to ever rise out of single digits. A feeling of appreciating every single day lasted thereafter, through the surgery and for many weeks afterwards. But as I returned to work and normality exerts itself with all its everyday stresses and interactions, it is hard not to slip back to not appreciating every day. So did this scare return any of that? Frankly no. Of course I was very very much relieved. But mostly I felt sort of emotionally exhausted. I think it is helpful to achieve a certain detachment if one must live with uncertainty as we must with ITP. I fool myself into thinking that I am good at that until a day, like that day, arrives when I think my numbers are plummeting. It is humbling.

Regarding bruises – I rarely get any unless my numbers are 20 -60. That day I had none, so that was a clue that my numbers were OK. Also, when blood is drawn from me, I can sort of tell what range my numbers are in from how quickly clotting occurs in the dot from the needle puncture.

Poseymint’s post regarding the clotting/coagulation process is helpful. I’ll add this: it refers to “damage” to the blood vessel, which of course happens when we bump ourselves (or worst). But I think “spontaneous” bruising doesn’t need such damage. My understanding of it is that little holes occur all the time in everyone in blood vessel walls. These holes get corrected and this part of the normal process of replacing the vessel wall. There is a balance or homeostasis in this tissue of normal breakdown and buildup as there is in most (all?) tissues. However, if one’s platelet numbers are too low, then some of this “normal breakdown” doesn’t get corrected and there is bleeding = spontaneous bruise, without damage inflicted from outside the body.

Mark - my counts are over 200k and I get bruises all the time without provocation. I do notice a huge difference in the type of bruise though. The low count bruises that I got were huge (5 to 8 inches in diameter) and black and the normal bruises are smaller and not nearly as colorful. Also, the low count bruises never hurt when I pressed on them but the normal bruises do.

I've never been able to tell how my counts were by the needle puncture. How it clotted seemed to depend on how good the actual draw was.

As time goes on and your counts stay good, you'll start to relax and will eventually stop thinking about counts dropping.

Someone here posted recently a really clever guide to bruises - if a bruise is sore, you probably got it the normal way by clunking yourself somehow. If a bruise isnt' sore, maybe it is an ITP type bruise that occurred without a real injury.
Erica