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NBME 23 Answers

nbme23/Block 3/Question#38 (46.8 difficulty score)
A 5-year-old boy who has recently recovered ...
Immune destruction of platelets🔍

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submitted by sajaqua1(524),
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hTe wmrrao wshos eorrscprus ot eycoyht,tserr as ellw sa crgseaomteyak.y hTis si ot wohs uoy thta het sieus itsn' dorin,utdecpruno hiwch naesm tath we are oislgn RCB and tepstella mweoeerhs ei cdrosnteut.i hatT luser uot D dan E. erThe si ohtignn ot diaincte tha eht cidhl sha edtieasmnids uelcsobtsuir .)(B tA ihst opint we ear ltef thwi A ro C. A dwoul aitecidn sdinatmsieeD rsnaItaavurlc oulatingCao CID)( ro ontmgheis slim,rai hchwi wuold reluts ni wol elatstpel dan CBR ubt ew dlwuo oasl ese mnorlaba CBR ekli hsseiyoctcst e"em"h(lt .lecls) eW era ictplyilxe tdlo atth eth oyrrhttscyee aer momhcnrircoo dna oyt.iocrmcn H,vweroe mineum itnsouedrtc of atelseptl ianlpsxe it l-al teh nietdsuotrc fo paltlseet slead to mose hgerhamrigon nad os a dpro ni BRC, adn TIP syscaliclal sareis rtaef a ctreen eppru yrtiosrerpa trcat lrvia tn.nfeciio

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12  
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +6  
abhishek021196  That is exactly how I approached this question. Normal heme panel and a decreased Platelet count in a young boy after an infection just made me intuitively select ITP. +  

submitted by seagull(1437),
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yWh is stih ont SU?H How idd oyu guys phoacrap the ioesn?utq

joonam  I think if this was HUS (d/t a bacterial infection) the leukocyte count would be abnormal (11k<) +  
yotsubato  normochromic normocytic RBC thats why. You would see schistocytes +9  
vulcania  Also for HUS I would expect mention of h/o bloody diarrhea, or at least diarrhea (not URI), and mention of something to do with kidney damage. +  

submitted by consistentwrongdoer3(17),
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hWat aer ew uspsdeop ot eb kiogoln a?t I ese uutdlmtcnelaei agtni .lcsle I asol ese tntefrliai (t’nca ellt if sthi si ooenlrnucma or .)otn

methylased  Young child following URI with TCP is pretty classic ITP. Sometimes they throw in extra stuff on purpose, but I didn’t see much on the bone marrow aspirate either. +7  
mousie  I was also thinking ITP but the bone marrow image kind of threw me off too, not sure what I'm supposed to see but still think ITP is best choice ... +  
meningitis  It also almost threw me off, but then I remembered he had low platelet count and I guessed those multinucleated cells were Megakaryocytes (I looked for Megakaryocyte Bone Marrow Biopsy in google and they are the same). +1  
what  Bone marrow shows increased megakaryocytes -> ITP +