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Visweshwar N, Ayala I, Jaglal M, Killeen R, Sokol L, Laber DA, Manoharan A. Primary immune thrombocytopenia: a 'diagnosis of exclusion'? Blood Coagul Fibrinolysis 2022; 33:289-294. [PMID: 35867940 PMCID: PMC9415225 DOI: 10.1097/mbc.0000000000001144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 01/19/2023]
Abstract
Current diagnosis of primary immune thrombocytopenia (ITP) is presumptive, centered on excluding other causes of thrombocytopenia. The diagnosis of ITP is challenging because of the wide range of potential inherited and acquired causes of thrombocytopenia. The treatment of ITP is empiric with steroids, high-dose immunoglobulin, immunosuppressants and thrombopoietin agonists with potential side effects. We searched Medline and Cochrane databases, reviewed the study data and analyzed the individual diagnostic tests for their evidence-based role in the diagnosis of ITP. We then analyzed the strength of the scientific evidence for each diagnostic test in the diagnosis of ITP and identified gaps in the diagnostic accuracy. The diagnostic challenges in ITP include: insufficient evidence for the individual test for diagnosis of ITP, no standardized protocol/guideline for diagnosis, hurdles in accessing the available resources and failure to correlate the clinical data while reviewing the blood smear. We did not identify a diagnostic test that clinicians can use to confirm the diagnosis of ITP. In the absence of a diagnostic test of proven value in ITP, the clinician is best served by a comprehensive history and physical examination, complete blood count and review of the peripheral blood smear in evaluating thrombocytopenia.
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Affiliation(s)
| | - Irmel Ayala
- Division of Hematology, Johns Hopkins All Children's Hospital, St. Petersburg
| | | | | | - Lubomir Sokol
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Arumugam Manoharan
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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Khan H, Ullah H, Khattak S, Aschner M, Aguilar CN, Halimi SMA, Cauli O, Shah SMM. Therapeutic potential of alkaloids in autoimmune diseases: Promising candidates for clinical trials. Phytother Res 2020; 35:50-62. [PMID: 32667693 DOI: 10.1002/ptr.6763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/23/2020] [Accepted: 05/16/2020] [Indexed: 02/05/2023]
Abstract
Clinical investigations have characterized numerous disorders like autoimmune diseases, affecting the population at a rate of approximately 8-10%. These disorders are characterized by T-cell and auto-antibodies responses to self-molecules by immune system reactivity. Several therapeutic options have been adopted in clinics to combat such diseases, however, most of them are recurring. Thus, the discovery of new effective agents for the treatment of autoimmune diseases is paramount. In this context, natural products might be a useful alternative to the current therapies. Plant alkaloids with their substantial therapeutic history can be particularly interesting candidates for the alleviation of autoimmune ailments. This review encompasses various alkaloids with significant effects against autoimmune diseases in preclinical trials. These results suggest further clinical assessment with respect to autoimmune illnesses. Furthermore, the application of modern technologies such as nanoformulation could be also helpful in the design of more effective therapies and thus further studies are needed to decipher their therapeutic efficacy as well as potential limitations.
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Affiliation(s)
- Haroon Khan
- Abdul Wali khan university Mardan, Abdul Wali khan university Mardan, Department of Pharmacy, Abdul Wali Khan university Mardan, Pakistan, Mardan, Pakistan, 23200, Pakistan
| | - Hammad Ullah
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Sumaira Khattak
- Abdul Wali khan university Mardan, Abdul Wali khan university Mardan, Department of Pharmacy, Abdul Wali Khan university Mardan, Pakistan, Mardan, Pakistan, 23200, Pakistan
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, New York, New York, USA
| | - Cristobal N Aguilar
- School of Chemistry, Universidad Autónoma de Coahuila Saltillo, Saltillo, Mexico
| | - Syed M A Halimi
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Omar Cauli
- Department of Nursing, University of Valencia, Valencia, Spain
| | - Syed M M Shah
- Department of Pharmacy, University of Swabi Pakistan, Swabi, Pakistan
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Bilateral Pulmonary Embolism With Right Heart Strain in a Patient With Immune Thrombocytopenia-A Case Report and Review of the Literature. Pediatr Emerg Care 2020; 36:e227-e228. [PMID: 32195985 DOI: 10.1097/pec.0000000000002075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients with immune thrombocytopenia are at risk of both bleeding complications and venous thromboembolism. There is no standard to treating life-threatening pulmonary embolism in this population. This case illustrates the difficulty of treating significant thromboembolism in pediatric patients who have reduced clotting capacity. CASE This case focuses on a 16-year-old pediatric patient with a history of immune thrombocytopenia presenting with mild chest discomfort and dyspnea on exertion. The d-dimer was mildly elevated, and the subsequent computed tomography angiogram revealed bilateral pulmonary embolisms with right ventricular strain. CONCLUSIONS The patient underwent thromboembolectomy by interventional radiology with subsequent administration of intravenous immunoglobulin, high-dose steroids, and enoxaparin therapy. There is no standard of care for patients with life-threatening pulmonary embolism in this population. Several authors suggest medical therapy options, but do not include patients with potential hemodynamic instability.
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Singh G, Bansal D, Wright NAM. Immune Thrombocytopenia in Children: Consensus and Controversies. Indian J Pediatr 2020; 87:150-157. [PMID: 31927692 DOI: 10.1007/s12098-019-03155-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023]
Abstract
Newly diagnosed immune thrombocytopenia (ITP) is a relatively common disorder of childhood that does not require an exhaustive laboratory workup for diagnosis. A history and physical exam with a review of the peripheral smear are crucial for excluding secondary causes of thrombocytopenia. Several guidelines have been published to guide physicians in the management of ITP. However, the decision for treatment can be arduous. The management strategy should not be focussed on the platelet count but the severity of bleeding symptoms. Agents for treating acute ITP, including corticosteroids, immunoglobulin and anti-D immunoglobulin, do not seem to have a significant impact on the natural history of the disease. The majority of children with ITP do not need therapy and have a spontaneous resolution of the disease. Some children can develop chronic ITP that is not commonly life-threatening but can lead to impaired quality of life. Traditional therapies such as rituximab and splenectomy for chronic ITP are not without significant adverse effects. Thrombopoietin receptor agonists are newer agents for the treatment of chronic ITP and hold promise, however, their cost currently precludes use in most of the patients in low-middle-income countries. This review compares and contrasts the specific treatments available for the treatment of ITP to help the reader make a balanced choice. This review, based on a series of case examples, will help physicians in making decisions about choosing a practical management strategy for patients with newly diagnosed as well as chronic ITP.
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Affiliation(s)
- Gurpreet Singh
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nicola A M Wright
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada.
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Hellmich B, Löffler C. [What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:955-966. [PMID: 31485728 PMCID: PMC7101899 DOI: 10.1007/s00393-019-00687-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.
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Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
| | - C Löffler
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland
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Elalfy M, Reda M, Elghamry I, Elalfy O, Meabed M, El-Ekiaby N, El-Hawy MA, Goubran H, El-Ekiaby M. A randomized multicenter study: safety and efficacy of mini-pool intravenous immunoglobulin versus standard immunoglobulin in children aged 1-18 years with immune thrombocytopenia. Transfusion 2017; 57:3019-3025. [PMID: 28880361 DOI: 10.1111/trf.14301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 07/02/2017] [Accepted: 07/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Because there is a global shortage of intravenous immunoglobulin, there is a need for new products to fill the gap. STUDY DESIGN AND METHODS This was a multicenter, open-label study investigating the safety and efficacy of a newly developed mini-pool intravenous immunoglobulin G for children with immune thrombocytopenia. Seventy-two patients ages 1 to 18 years with newly diagnosed (<1 month) immune thrombocytopenia who had platelet counts from 5 to 20 × 109 /L with no serious bleeding were recruited from four centers in Egypt. Eligible patients were randomized into three groups 1:1:1. Group A (n = 24) received blood group-specific mini-pool intravenous immunoglobulin in a dose equivalent to immunoglobulin 1 g/kg over 6 to 8 hours, Group B (n = 24) received standard intravenous immunoglobulin (approximately 1g/kg) as a single dose, and Group C (n = 24) did not receive any platelet-enhancing therapy. Parents signed informed consent. RESULTS Of the patients who received mini-pool intravenous immunoglobulin, 14 achieved a complete response (CR) (58.8%), and four had a response (16.6%). Of the patients who received intravenous immunoglobulin G, 16 achieved a complete response (66.6%), and four had a response (16.6%). In Group C, eight patients achieved a complete response (33.3%), and four had a response (16.6%). The median time to response was 8, 9, and 21 days in Group A, B, and C, respectively, which was significantly higher in Group C than Groups A and B (p < 0.001). Patients in Groups A and B reported 16 adverse drug reactions. CONCLUSION Mini-pool intravenous immunoglobulin G was well tolerated, presented no safety issues, and was effective in the treatment of immune thrombocytopenia, with efficacy comparable to that of the standard intravenous immunoglobulin G group, and it was significantly more effective than no treatment.
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Affiliation(s)
- Mohsen Elalfy
- Department of Pediatric Hematology, Ain Shams University Hospitals, National Research Center, Cairo, Egypt
| | - Marwa Reda
- Department of Pediatric Hematology, Ain Shams University Hospitals, National Research Center, Cairo, Egypt
| | - Islam Elghamry
- Department of Pediatric Hematology, Ain Shams University Hospitals, National Research Center, Cairo, Egypt
| | - Omar Elalfy
- Complementary Medicine Department, National Research Center, Cairo, Egypt
| | - Mohamed Meabed
- Department of Pediatrics, Beni-Suef University, Beni-Suef, Egypt
| | - Nada El-Ekiaby
- School of Medicine, Health Sciences Research Department, New Giza University, Giza, Egypt
| | | | - Hadi Goubran
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Magdy El-Ekiaby
- Hematology Unit, Blood Transfusion Center, Shabrawishi Hospital, Giza, Egypt
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Koylu A, Pamuk GE, Uyanik MS, Demir M, Pamuk ON. Immune thrombocytopenia: epidemiological and clinical features of 216 patients in northwestern Turkey. Ann Hematol 2014; 94:459-66. [DOI: 10.1007/s00277-014-2220-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/11/2014] [Indexed: 12/14/2022]
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Li Y, Pankaj P, Wang X, Wang Y, Peng B. Splenectomy in the management of Evans syndrome in adults: Long-term follow up of 32 patients. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yongbin Li
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Prasoon Pankaj
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Xin Wang
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Yichao Wang
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Bing Peng
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
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Elalfy MS. Three Decades of Experience in Managing Immune Thrombocytopenia in Children in Arab Countries. Semin Hematol 2013; 50 Suppl 1:S22-5. [DOI: 10.1053/j.seminhematol.2013.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Romiplostim in children with chronic refractory ITP: randomized placebo controlled study. Ann Hematol 2011; 90:1341-4. [PMID: 21318572 DOI: 10.1007/s00277-011-1172-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
Abstract
Romiplostim stimulates thrombopoietin receptor to increase platelet production of megakaryocytes in idiopathic thrombocytopenic purpura (ITP). This study aimed to evaluate the safety and efficacy of romiplostim in children with chronic ITP. Eighteen patients with chronic ITP, either none responsive or failed to maintain response on two or more therapeutic modalities, were enrolled. Patients were randomized (2:1) to receive romiplostim or placebo for 12 weeks, initiated at 1 μg/kg/week, escalated to 5 μg/kg/week, and then tapered. Median patients' age was 8.5 years, and the median baseline platelet count (PC) was 10.5 × 10(9)/L. The median weekly dose of romiplostim was 2 μg/kg. Fifty percent of patients in both romiplostim and placebo arms had at least one adverse event (AE); none was serious. Ten patients on romiplostim (83.3%) maintained the efficacy endpoint (PC > 50,000). Romiplostim was well-tolerated and efficient in treating the children with chronic refractory ITP with no unexpected AEs.
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