An Unusual Endoscopic Finding: “Polka Dot Stomach”

Abstract

A 57-year-old woman with no significant past medical history presented to the emergency department with 2 days of melena, epistaxis, purpura, fatigue, and malaise. She endorsed taking sulfamethoxazole/trimethoprim (TMP/SMX) for a sinus infection for 8 days prior to admission. She denied any prior GI bleeding and had a normal screening colonoscopy 6 years prior. She had rare NSAID use and no other medication use. Physical exam revealed purpura on the hard and soft palate, buccal mucosa, and tongue (Figure 1). Petechiae were present on the bilateral lower extremities (Figure 2). Her initial laboratory results revealed severe anemia, hemoglobin (Hgb) of 5.2 g/dL, and severe thrombocytopenia, platelets of 2 K/uL. The Hgb had decreased from 13 g/dL to 5.2 g/dL over 1 day, and platelets had decreased from 199 K/uL to 2 K/uL over 1 week. Her WBC, blood chemistry, coagulation studies, and liver function tests were unremarkable. She received 2 units of packed RBCs, raising the Hgb to 7.7 g/dL and 6 units of platelets. She received upper endoscopy to help determine the etiology of the melena. This showed diffuse gastric petechiae with oozing as the source of the bleed (Figure 3). Based on these findings, immune thrombocytopenic purpura (ITP) or drug-induced immune thrombocytopenia (DITP) leading to upper GI bleeding was the likely diagnosis. The patient was started on IV methylprednisolone and IVIG. Further laboratory studies for HIV, HCV, and other autoimmune serology were negative, excluding secondary ITP. ITP and DITP are similar in that both involve the autoimmune destruction of platelets; however, ITP has no known trigger, whereas DITP is triggered by a drug. TMP/SMX is among a list of drugs known to cause platelet-reactive antibodies. In the acute setting, ITP cannot be distinguished from DITP. As such, steroids, IVIG, and platelet transfusions were started for treatment because of the clinical severity of GI bleeding. The suspected culprit drug was discontinued. The patient's anemia and thrombocytopenia improved over the next several days with the course of IV steroids and IVIG, and she was discharged on an oral steroid taper. Her Hgb and platelets were normal by one-month follow-up. The endoscopic findings of bleeding from ITP or DITP are very rare with only a few case reports to our knowledge. The characteristic stomach petechiae causing a “polka dot” appearance should be noted in patients with ITP or DITP and severely low platelets.Figure 1Figure 2Figure 3