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González-López TJ, Newland A, Provan D. Current Concepts in the Diagnosis and Management of Adult Primary Immune Thrombocytopenia: Our Personal View. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:815. [PMID: 37109773 PMCID: PMC10143742 DOI: 10.3390/medicina59040815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired blood disorder that causes a reduction in circulating platelets with the potential for bleeding. The incidence of ITP is slightly higher in adults and affects more women than men until 60 years, when males are more affected. Despite advances in basic science, primary ITP remains a diagnosis of exclusion. The disease is heterogeneous in its clinical behavior and response to treatment. This reflects the complex underlying pathophysiology, which remains ill-understood. Platelet destruction plays a role in thrombocytopenia, but underproduction is also a major contributing factor. Active ITP is a proinflammatory autoimmune disease involving abnormalities within the T and B regulatory cell compartments, along with several other immunological abnormalities. Over the last several years, there has been a shift from using immunosuppressive therapies for ITP towards approved treatments, such as thrombopoietin receptor agonists. The recent COVID-19 pandemic has hastened this management shift, with thrombopoietin receptor agonists becoming the predominant second-line treatment. A greater understanding of the underlying mechanisms has led to the development of several targeted therapies, some of which have been approved, with others still undergoing clinical development. Here we outline our view of the disease, including our opinion about the major diagnostic and therapeutic challenges. We also discuss our management of adult ITP and our placement of the various available therapies.
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Affiliation(s)
| | - Adrian Newland
- Academic Haematology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK
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Hemmati S, Poor Heravi MR, Nami N, Khalilzadeh MA. Novel One-Pot Pseudo-Five-Component Green Synthesis and Biological Activities In Vitro of 5,5′-(Arylmethylene)Bis (4-Hydroxythiazol-2(3 H)-One) Using Triton-X-100 as High Efficient Catalytic System. Polycycl Aromat Compd 2022. [DOI: 10.1080/10406638.2022.2048033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sana Hemmati
- Department of Chemistry, Qaemshahr Branch, Islamic Azad University, Qaemshahr, Iran
| | | | - Navabeh Nami
- Department of Chemistry, Qaemshahr Branch, Islamic Azad University, Qaemshahr, Iran
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PARLAR M, ACIPAYAM C, DİNÇER S, GÜLLÜ UU, ÇOBANUŞAĞI M, MARAŞLI H. Çocukluk Çağı İmmün Trombositopenik Purpura (İTP) Hastalarının Yaş Gruplarına Göre Değerlendirilmesi. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.811899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Hussman JP. Cellular and Molecular Pathways of COVID-19 and Potential Points of Therapeutic Intervention. Front Pharmacol 2020; 11:1169. [PMID: 32848776 PMCID: PMC7406916 DOI: 10.3389/fphar.2020.01169] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/17/2020] [Indexed: 12/20/2022] Open
Abstract
With the objective of linking early findings relating to the novel SARS-CoV-2 coronavirus with potentially informative findings from prior research literature and to promote investigation toward therapeutic response, a coherent cellular and molecular pathway is proposed for COVID-19. The pathway is consistent with a broad range of observed clinical features and biological markers and captures key mediators of pathophysiology. In this proposed pathway, membrane fusion and cytoplasmic entry of SARS-CoV-2 virus via ACE2 and TMPRSS2-expressing respiratory epithelial cells, including pulmonary type-II pneumocytes, provoke an initial immune response featuring inflammatory cytokine production coupled with a weak interferon response, particularly in IFN-λ-dependent epithelial defense. Differentiation of non-classic pathogenic T-cells and pro-inflammatory intermediate monocytes contributes to a skewed inflammatory profile, mediated by membrane-bound immune receptor subtypes (e.g., FcγRIIA) and downstream signaling pathways (e.g., NF-κB p65 and p38 MAPK), followed by chemotactic infiltration of monocyte-derived macrophages and neutrophils into lung tissue. Endothelial barrier degradation and capillary leakage contribute to alveolar cell damage. Inflammatory cytokine release, delayed neutrophil apoptosis, and NETosis contribute to pulmonary thrombosis and cytokine storm. These mechanisms are concordant with observed clinical markers in COVID-19, including high expression of inflammatory cytokines on the TNF-α/IL-6 axis, elevated neutrophil-to-lymphocyte ratio (NLR), diffuse alveolar damage via cell apoptosis in respiratory epithelia and vascular endothelia, elevated lactate dehydrogenase (LDH) and CRP, high production of neutrophil extracellular traps (NETs), depressed platelet count, and thrombosis. Although certain elements are likely to be revised as new findings emerge, the proposed pathway suggests multiple points of investigation for potential therapeutic interventions. Initial candidate interventions include prophylaxis to augment epithelial defense (e.g., AT1 receptor blockade, type III and type I interferons, melatonin, calcitriol, camostat, and lopinavir) and to reduce viral load (e.g., remdesivir, ivermectin, emetine, Abelson kinase inhibitors, dopamine D2 antagonists, and selective estrogen receptor modulators). Additional interventions focus on tempering inflammatory signaling and injury (e.g., dexamethasone, doxycycline, Ang1-7, estradiol, alpha blockers, and DHA/EPA, pasireotide), as well as inhibitors targeted toward molecular mediators of the maladaptive COVID-19 immune response (e.g., IL-6, TNF-α, IL-17, JAK, and CDK9).
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Tomassetti M, Lupidi G, Piermattei P, Rossi FV, Lillini S, Bianchini G, Aramini A, Ciufolini MA, Marcantoni E. Catalyst-Free Synthesis of Polysubstituted 5-Acylamino-1,3-Thiazoles via Hantzsch Cyclization of α-Chloroglycinates. Molecules 2019; 24:molecules24213846. [PMID: 31731437 PMCID: PMC6864457 DOI: 10.3390/molecules24213846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/17/2022] Open
Abstract
A catalyst-free heterocyclization reaction of α-chloroglycinates with thiobenzamides or thioureas leading to 2,4-disubstituted-5-acylamino-1,3-thiazoles has been developed. The methodology provides straightforward access to valuable building blocks for pharmaceutically relevant compounds.
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Affiliation(s)
- Mara Tomassetti
- Dompé Farmaceutici S.p.A., Via Pietro Castellino, Napoli 80131, Italy; (S.L.); (A.A.)
- Correspondence: (M.T.); (E.M.); Tel.: +39-(816)-132-220 (M.T.); Tel.: +39-(737)-402-255 (E.M.)
| | - Gabriele Lupidi
- School of Science and Technology, Chemistry Division, University of Camerino, Camerino 62032, Italy; (G.L.); (P.P.); (F.V.R.)
| | - Pamela Piermattei
- School of Science and Technology, Chemistry Division, University of Camerino, Camerino 62032, Italy; (G.L.); (P.P.); (F.V.R.)
| | - Federico V. Rossi
- School of Science and Technology, Chemistry Division, University of Camerino, Camerino 62032, Italy; (G.L.); (P.P.); (F.V.R.)
| | - Samuele Lillini
- Dompé Farmaceutici S.p.A., Via Pietro Castellino, Napoli 80131, Italy; (S.L.); (A.A.)
| | | | - Andrea Aramini
- Dompé Farmaceutici S.p.A., Via Pietro Castellino, Napoli 80131, Italy; (S.L.); (A.A.)
- Dompé Farmaceutici S.p.A., Via Campo di Pile, L’Aquila 67100, Italy;
| | - Marco A. Ciufolini
- Department of Chemistry, University of British Columbia, 2036 Main Mall, Vancouver, BC V6T 1Z1, Canada;
| | - Enrico Marcantoni
- School of Science and Technology, Chemistry Division, University of Camerino, Camerino 62032, Italy; (G.L.); (P.P.); (F.V.R.)
- Correspondence: (M.T.); (E.M.); Tel.: +39-(816)-132-220 (M.T.); Tel.: +39-(737)-402-255 (E.M.)
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Hemoperitoneum after Ovulation in Systemic Lupus Erythematosus and Autoimmune Thrombocytopenia. Case Rep Obstet Gynecol 2019; 2019:7201650. [PMID: 30792931 PMCID: PMC6354148 DOI: 10.1155/2019/7201650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/15/2018] [Accepted: 01/05/2019] [Indexed: 11/23/2022] Open
Abstract
Background Three prior cases of hemoperitoneum associated with immune thrombocytopenia (ITP) have been reported in adolescents. This reports a case of hemoperitoneum after ovulation in an adult. Case A 34-year-old nulligravida presented with abdominal pain after a heavy period and rebound tenderness. Urine beta-hCG was negative, hemoglobin was 5.4, and platelet count was zero. CT revealed hemoperitoneum and contrast blush surrounding the left ovary. She was treated for newly diagnosed systemic lupus erythematosus and steroid-refractory ITP. Her platelet count and symptoms improved. Conclusion Hemoperitoneum after ovulation in ITP is rare; this represents the first adult case in the literature and reviews differential diagnosis of thrombocytopenia. The obstetrician/gynecologist is part of a multidisciplinary team caring for patients with bleeding of gynecological origin and should withhold surgical intervention for hemoperitoneum when medical therapy is warranted.
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Nazy I, Kelton JG, Moore JC, Clare R, Horsewood P, Smith JW, Ivetic N, D'Souza V, Li N, Arnold DM. Autoantibodies to thrombopoietin and the thrombopoietin receptor in patients with immune thrombocytopenia. Br J Haematol 2018. [DOI: 10.1111/bjh.15165] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Ishac Nazy
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
- McMaster Centre for Transfusion Research; Department of Medicine; McMaster University; Hamilton ON Canada
| | - John G. Kelton
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
| | - Jane C. Moore
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton ON Canada
| | - Rumi Clare
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
| | - Peter Horsewood
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
| | - James W. Smith
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
| | - Nikola Ivetic
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
- Department of Biochemistry and Biomedical Sciences; McMaster University; Hamilton ON Canada
| | - Vanessa D'Souza
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
- Department of Biochemistry and Biomedical Sciences; McMaster University; Hamilton ON Canada
| | - Na Li
- McMaster Centre for Transfusion Research; Department of Medicine; McMaster University; Hamilton ON Canada
| | - Donald M. Arnold
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
- McMaster Centre for Transfusion Research; Department of Medicine; McMaster University; Hamilton ON Canada
- Canadian Blood Services; Hamilton ON Canada
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Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia. Blood 2017; 129:2829-2835. [PMID: 28416506 PMCID: PMC5813736 DOI: 10.1182/blood-2017-03-754119] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 12/25/2022] Open
Abstract
Immune thrombocytopenia (ITP) occurs in 2 to 4/100 000 adults and results in variable bleeding symptoms and thrombocytopenia. In the last decade, changes in our understanding of the pathophysiology of the disorder have led to the publication of new guidelines for the diagnosis and management of ITP and standards for terminology. Current evidence supports alternatives to splenectomy for second-line management of patients with persistently low platelet counts and bleeding. Long-term follow-up data suggest both efficacy and safety, in particular, for the thrombopoietin receptor agonists and the occurrence of late remissions. Follow-up of patients who have undergone splenectomy for ITP reveals significant potential risks that should be discussed with patients and may influence clinician and patient choice of second-line therapy. Novel therapeutics are in development to address ongoing treatment gaps.
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MESH Headings
- Adult
- Female
- Hemorrhage/blood
- Hemorrhage/diagnosis
- Hemorrhage/physiopathology
- Hemorrhage/therapy
- Humans
- Male
- Platelet Count
- Practice Guidelines as Topic
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/metabolism
- Splenectomy
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Affiliation(s)
- Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA; and
| | - Terry B Gernsheimer
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
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Consolini R, Costagliola G, Spatafora D. The Centenary of Immune Thrombocytopenia-Part 2: Revising Diagnostic and Therapeutic Approach. Front Pediatr 2017; 5:179. [PMID: 28871277 PMCID: PMC5566994 DOI: 10.3389/fped.2017.00179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children and adolescents and can be considered as a paradigmatic model of autoimmune disease. This second part of our review describes the clinical presentation of ITP, the diagnostic approach and overviews the current therapeutic strategies. Interestingly, it suggests an algorithm useful for differential diagnosis, a crucial process to exclude secondary forms of immune thrombocytopenia (IT) and non-immune thrombocytopenia (non-IT), which require a different therapeutic management. Advances in understanding the pathogenesis led to new therapeutic targets, as thrombopoietin receptor agonists, whose role in treatment of ITP will be discussed in this work.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Davide Spatafora
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Bakchoul T, Sachs UJ. Platelet destruction in immune thrombocytopenia. Understanding the mechanisms. Hamostaseologie 2015; 36:187-94. [PMID: 25982994 DOI: 10.5482/hamo-14-09-0043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 05/04/2015] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia. A dysfunctional proliferation of autoreactive T cells is suggested to be responsible for the loss of tolerance to self-platelet antigens in ITP patients. Autoreactive T cells induce uncontrolled proliferation of autoantibody producing B cells leading to persistent anti-platelet autoimmunity in some ITP patients. The autoimmune response causes an increased destruction of platelets by antibody-mediated phagocytosis, complement activation but also by T cell mediated cytotoxicity. In addition, abnormalities in thrombopoiesis and insufficient platelet production due to antibody or T cell mediated megakaryocyte inhibition and destruction contribute to the pathophysiology of ITP. These various effector cell responses may account for the heterogeneity in the clinical manifestation of ITP and also, to success or failure of different treatment strategies. A better understanding of the mechanisms behind ITP will hopefully allow for better diagnostic and, particularly, therapeutic strategies in the future.
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Affiliation(s)
- Tamam Bakchoul
- Prof. Dr. med. Tamam Bakchoul, Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany, Tel. +49/(0)38 34/86 54 58, Fax +49/(0)38 34/86 54 89, E-mail:
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