Cytomegalovirus-associated Immune Thrombocytopenic Purpura After Liver Transplantation

Prevalence of Cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) Subclinical Infection in Patients with Acute Immune Thrombocytopenic Purpura (ITP)

Background: Immune thrombocytopenic purpura (ITP) defined as a bleeding disorder in which the number and production of platelets reduced by the immune system; however, the destruction of peripheral blood platelets also occurs. Although its exact etiology and pathogenesis not already know, several studies have shown that Epstein-Barr virus (EBV) and cytomegalovirus (CMV) known as possible causative agents of ITP. This investigation aims to evaluate the presence of CMV and EBV in two groups of case and control by polymerase chain reaction (PCR).

Materials and Methods: we considered the presence of CMV and EBV in 48 acute ITP patients and 48 healthy people. Study participants were recruited from Ahvaz Shafa Hospital between 2017 and 2018 and the presence of two viruses was investigated by (PCR).

Results: Out of 48 acute ITP patients, the CMV DNA was detected from the blood of 12 (25%) patients and the EBV DNA from the blood of 2 (4.2%) other patients. In addition, only one patient was (2.1%) co-infected with CMV and EBV. In contrast, in 48 healthy subjects, 3 (6.6%) had CMV and none of the control group was infected with EBV.

Conclusion: Due to the presence of both EBV and CMV in the acute ITP patients in Ahvaz, they can be considered as factors in the progression of this disease. Therefore, consideration of the methods of elimination and treatment of these two viruses in these patients may be used as a treatment strategy in ITP patients in the future.

Dermatological Disorders following Liver Transplantation: An Update

Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.

Successful Treatment of Idiopathic Thrombocytopenic Purpura After Liver Transplant: A Case Report

Idiopathic thrombocytopenic purpura, a common acquired bleeding disorder in pediatric patients, is an autoimmune disorder characterized by a low platelet count. Organ transplant can transfer such diseases, but the occurrence of idiopathic thrombocytopenic purpura after liver transplant is rare. Here, we report a 17-month-old girl who was diagnosed with idiopathic thrombocytopenic purpura and who had a history of liver transplant 11 months earlier. Treatment of cytomegalovirus and Epstein-Barr virus infection led to a successful outcome.

Immune Thrombocytopenic Purpura Secondary to Cytomegalovirus Infection: A Case Report

Immune thrombocytopenic purpura (ITP) is defined as an acquired thrombocytopenia with antibodies detected against platelet surface antigens, and it is the most common form of thrombocytopenia in otherwise asymptomatic adults. ITP secondary to an underlying condition is a diagnosis of exclusion that is essential to establish for treatment efficacy. Secondary thrombocytopenia caused by cytomegalovirus (CMV) is common; however, case reports associated with diagnosis in immunocompetent adults are rare, and to the best of our knowledge only 20 publications have been associated with this diagnosis. Our report is based on a clinical presentation of a 37-year-old female complaining of petechiae, heavy menses, shortness of breath, and a platelet count of 1 × 10⁹/L. Treatment with IVIG and steroids failed to improve platelet count. Subsequently, an infectious laboratory workup was performed, detecting CMV infection, and treatment with antiviral agents was initiated, causing platelet count to increase as viral load decreased.

The role of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) in immune thrombocytopenia

BACKGROUND

Although Epstein-Barr virus (EBV) and cytomegalovirus (CMV) are known to trigger immune thrombocytopenia (ITP), the manifestations of EBV and CMV in ITP spleen tissues continue to be poorly understood.

METHODS

Our research retrospectively reviewed a total of 42 ITP patients and 20 healthy control cases from the West China Hospital of Sichuan University from 2008 to 2012. Patients' characteristics, preoperative platelet counts, and the expression of EBV and CMV in spleen tissue were analyzed.

RESULTS

No statistically significant differences were identified for age and gender between the ITP group and the healthy control group. The comparison of these two categories (the ITP group and the control group) showed substantial variations in the expression of EBV and CMV: nine (21.4%) and eight (19%) ITP patients had a positive expression of EBV and CMV, compared with none and one patient in the control group, respectively. In the EBV-ITP group, patients with a positive EBV expression revealed appreciably decreased preoperative platelet count compared with patients with a negative EBV expression. No other statistically significant difference was found in the CMV group.

CONCLUSION

We have demonstrated the presence of both EBV and CMV infections in the spleen tissue of ITP patients. EBV infections were implicated in the reduced platelet counts in ITP.

Autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura in pediatric solid organ transplant recipients, report of five cases and review of the literature

Cytopenias are common among pediatric SOT; however, autoimmune cytopenias are infrequently reported. We report five cases of autoimmune cytopenias in pediatric LT patients: two with isolated IgG-mediated AIHA, two with ITP, and one with Evans syndrome (ITP and AIHA). All patients were maintained on tacrolimus as immunosuppression. Viral illness commonly preceded the autoimmune cytopenias. All patients responded well to medical therapy (steroids, intravenous immunoglobulin, and rituximab) and lowering tacrolimus serum level. Prognosis appears to be worse when more than one cell line (e.g., Evans syndrome) is affected, and/or there is no preceding viral illness. A critical literature review of autoimmune cytopenias in children following SOT is conducted. Autoimmune cytopenias are a rarely reported complication of pediatric SOT, but clinicians taking care of pediatric transplant recipients need to be aware of this complication.

Cytomegalovirus-associated idiopathic thrombocytopenic purpura in Chinese children

The objective was to investigate the clinical features, glycoprotein B (gB) genotype and therapy of the human cytomegalovirus (CMV)-associated idiopathic thrombocytopenic purpura (ITP) in Chinese children. Clinical features and laboratory data of 25 CMV-associated ITP, including 18 males and 7 females with a median age of 0.3 y, were analysed and compared with 116 CMV-negative ITP. The CMV gB of 17 cases was genotyped. Apart from dermatorrhagia, jaundice was noted in 6 cases. Cough, diarrhoea, fever, splenohepatomegaly, alimentary tract haemorrhage and raised ALT were also found. Compared with CMV-negative ITP, CMV-associated ITP has a younger median age, raised ALT and AST, and longer hospitalization (p<0.05, respectively). The most prevalent genotype was gB1 (15/17), followed by coinfection and gB3. Compared with congenitally CMV-infected children in our previous study, more prevalence of gB1 was noted (40/79 vs 15/17, p=0.004). Most of these cases were receiving the therapy of immunoglobulin, corticoid and/or gancyclovir with good therapeutic effect except for 2 cases. In conclusion, CMV infection, especially gB1 genotype, is an important cause of ITP and careful examination of markers of CMV in all cases of apparent 'idiopathic' ITP is required. Combination therapy of immunoglobulin, corticoid and gancyclovir is effective.

Idiopathic thrombocytopenic purpura complicated with biliary atresia: a rare occurrence and literature review

The association of biliary atresia (BA) and idiopathic thrombocytopenic purpura (ITP) is extremely rare, with only 2 cases being reported in the literature. This report describes the very rare case of a 1-year-old boy with BA complicated with ITP after cholangitis and the successful steroid treatment of ITP. We review the literature on this type of relationship between BA and ITP and discuss the clinical features of this complication. Furthermore, the possible cause of the onset of ITP complicated with BA was explored in this report.