A Paradoxical Case of Bleeding and Clots: The Hidden Thrombotic Threat in Immune Thrombocytopenic Purpura.

Immune thrombocytopenic purpura (ITP) is typically characterized by mucocutaneous bleeding, yet paradoxical thrombotic events are increasingly recognized, particularly in patients treated with thrombopoietin-receptor agonists (TPO-RAs) such as eltrombopag. We describe a young woman with established ITP who developed deep vein thrombosis and pulmonary embolism shortly after commencing norethisterone for menstrual regulation while also using eltrombopag, creating a combination of therapeutic and physiological prothrombotic risks. Despite persistently low platelet counts, she presented with acute dyspnea, pleuritic chest pain, and unilateral lower limb swelling. CT pulmonary angiography demonstrated segmental pulmonary emboli, and Doppler ultrasonography confirmed lower limb thrombosis. Both eltrombopag and norethisterone were discontinued, and anticoagulation was initiated under close hematological supervision, resulting in clinical and radiological improvement with stabilization of platelet counts on follow-up. This case underscores the complex interplay between ITP, platelet-stimulating agents, and hormonal therapy, illustrating how thrombosis may occur even in the context of thrombocytopenia. It highlights the importance of maintaining a high index of suspicion for thromboembolic complications in ITP patients receiving TPO-RA therapy, particularly when additional risk factors coexist, and reinforces the need for careful risk-benefit assessment when initiating or continuing agents that may contribute to thrombogenesis.