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Frol S, Pretnar Oblak J, Šabovič M, Kermer P, Sever M. Treatment of Acute Ischaemic Stroke and Concomitant Multiple Arterial Splanchnic Thromboses in a Patient with Immune Thrombocytopenia on Thrombopoietin Agonist: A Case Report. Neurol Int 2023; 15:1191-1199. [PMID: 37755365 PMCID: PMC10537946 DOI: 10.3390/neurolint15030074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune blood disorder characterised by isolated severe thrombocytopenia. Arterial thrombotic events, such as acute ischaemic stroke (AIS), are rare complications. A 56-year-old woman with chronic ITP on eltrombopag and dexamethasone therapy presented to the emergency department due to AIS in the vertebrobasilar territory, and lower abdominal pain. The computed tomography (CT) scan of the head was unremarkable, whereas CT angiography revealed left vertebral artery occlusion. As the platelet count was sufficient, intravenous thrombolysis (IVT) was initiated. However, after 15 min, an anaphylactic reaction occurred, which was appropriately solved. Although the IVT was prematurely stopped, the NIHSS score improved from 7 to 2, and the follow-up head CT scan remained unremarkable. CT angiography of the thoracoabdominal aorta revealed multiple thrombi in the infrarenal aorta, inferior mesenteric artery (IMA), and left renal artery. The abdominal pain subsided after IVT, but recurred within 24 h. Repeated CT angiography showed ischaemia of the descending colon, with persistent IMA occlusion. After the hemicolectomy condition stabilised. Discrete left-sided ataxia and impaired sensation were the only neurological sequelae. We found two articles reporting only three patients with ITP who suffered AIS and were treated with IVT. A favourable outcome was observed in two cases, while one patient suffered an intracranial haemorrhage (ICH) and died. A review of AIS cases with undefined thrombocytopenia treated with IVT reported ICH in up to 6.8% of patients. Our case suggests that IVT for AIS may be effective in patients with ITP. Further data are needed to better clarify this issue.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mišo Šabovič
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Vascular Disorders, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, 26452 Sande, Germany
- Department of Neurology, University of Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - Matjaž Sever
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Haematology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
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Clot Waveform Analysis Demonstrates Low Blood Coagulation Ability in Patients with Idiopathic Thrombocytopenic Purpura. J Clin Med 2021; 10:jcm10245987. [PMID: 34945283 PMCID: PMC8705019 DOI: 10.3390/jcm10245987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/03/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although platelets, which contain large amounts of phospholipids, play an important role in blood coagulation, there is still no routine assay to examine the effects of platelets in blood coagulation. METHODS Hemostatic abnormalities in patients with thrombocytopenia, including those with idiopathic thrombocytopenic purpura (ITP), were examined using clot wave analysis (CWA)-small-amount tissue-factor-induced FIX activation (sTF/FIXa) and thrombin time (TT). RESULTS Although there were no marked differences in the three parameters of activated partial thromboplastin time (APTT) between normal healthy volunteers and typical patients with ITP, the peak heights of the CWA-sTF/FIXa were markedly low in patients with ITP. The three peak times of the CWA-sTF/FIXa in patients with a platelet count of ≤8.0 × 1010/L were significantly longer than those in patients with a platelet count > 8.0 × 1010/L and the peak heights of the CWA-sTF/FIXa in patients with a platelet count of ≤8.0 × 1010/L were significantly lower than those in patients with >8.0 × 1010/L. The peak heights of the CWA-APTT in patients with ITP were significantly lower than in patients with other types of thrombocytopenia. The three peak heights of the CWA-sTF/FIXa in ITP patients were significantly lower than those in patients with other types of thrombocytopenia. The CWA-TT showed lower peak heights and longer peak times in patients with ITP in comparison to patients with other types of thrombocytopenia. CONCLUSIONS The CWA-sTF/FIXa and CWA-TT results showed that blood coagulation is enhanced by platelets and that the blood coagulation ability in ITP patients was low in comparison to healthy volunteers and patients with other types of thrombocytopenia.
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Brøns N, Leinøe E, Salado-Jimena JA, Rossing M, Ostrowski SR. Levels of procoagulant microparticles expressing phosphatidylserine contribute to bleeding phenotype in patients with inherited thrombocytopenia. Blood Coagul Fibrinolysis 2021; 32:480-490. [PMID: 34475331 DOI: 10.1097/mbc.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inherited thrombocytopenia is a heterogeneous group of hereditary disorders with varying bleeding tendencies, not simply related to platelet count. Platelets transform into different subpopulations upon stimulation, including procoagulant platelets and platelet microparticles (PMPs), which are considered critical for haemostasis. We aimed to investigate whether abnormalities in PMP and procoagulant platelet function were associated with the bleeding phenotype of inherited thrombocytopenia patients. We enrolled 53 inherited thrombocytopenia patients. High-throughput sequencing of 36 inherited thrombocytopenia related genes was performed in all patients and enabled a molecular diagnosis in 57%. Bleeding phenotype was evaluated using the ISTH bleeding assessment tool, dividing patients into bleeding (n = 27) vs. nonbleeding (n = 26). Unstimulated and ADP, TRAP or collagen-stimulated PMP and procoagulant platelet functions were analysed by flow cytometry using antibodies against granulophysin (CD63), P-selectin (CD62P), activated GPIIb/IIIa (PAC-1) and a marker for phosphatidylserine expression (lactadherin). Procoagulant platelets were measured in response to collagen stimulation. An in-house healthy reference level was available. Overall, higher levels of activated platelets, PMPs and procoagulant platelets were found in nonbleeding patients compared with the reference level. Nonbleeding patients had higher proportions of phosphatidylserine and PMPs compared with bleeding patients and the reference level, in response to different stimulations. Interestingly, this finding of high proportions of phosphatidylserine and PMPs was limited to PMPs, and not present in procoagulant platelets or platelets. Our findings indicate that nonbleeding inherited thrombocytopenia patients have compensatory mechanisms for improved platelet subpopulation activation and function, and that generation of phosphatidylserine expressing PMPs could be a factor determining bleeding phenotype in inherited thrombocytopenia.
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Affiliation(s)
- Nanna Brøns
- Department of Hematology
- Department of Clinical Immunology
| | | | | | - Maria Rossing
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, København, Denmark
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Cooper N, Altomare I, Thomas MR, Nicolson PLR, Watson SP, Markovtsov V, Todd LK, Masuda E, Bussel JB. Assessment of thrombotic risk during long-term treatment of immune thrombocytopenia with fostamatinib. Ther Adv Hematol 2021; 12:20406207211010875. [PMID: 33995988 PMCID: PMC8111531 DOI: 10.1177/20406207211010875] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with immune thrombocytopenia (ITP) are at risk of bleeding and, paradoxically, thromboembolic events (TEEs), irrespective of thrombocytopenia. The risk of thrombosis is increased by advanced age, obesity, and prothrombotic comorbidities: cancer, hyperlipidemia, diabetes, hypertension, coronary artery disease, and chronic kidney disease, among others. Certain ITP treatments further increase the risk of TEE, especially splenectomy and thrombopoietin receptor agonists. Spleen tyrosine kinase (SYK) is a key signaling molecule common to thromboembolic and hemostatic (in addition to inflammatory) pathways. Fostamatinib is an orally administered SYK inhibitor approved in the USA and Europe for treatment of chronic ITP in adults. Methods: The phase III and extension studies included heavily pretreated patients with long-standing ITP, many of whom had risk factors for thrombosis prior to initiating fostamatinib. This report describes long-term safety and efficacy of fostamatinib in 146 patients with up to 5 years of treatment, a total of 229 patient-years, and assesses the incidence of thromboembolic events (by standardized MedDRA query). Results: Platelet counts ⩾50,000/µL were achieved in 54% of patients and the safety profile was as described in the phase III clinical studies with no new toxicities observed over the 5 years of follow-up. The only TEE occurred in one patient (0.7%, or 0.44/100 patient-years), who experienced a mild transient ischemic attack. This is a much lower rate than might be expected in ITP patients. Conclusion: This report demonstrates durable efficacy and a very low incidence of TEE in patients receiving long-term treatment of ITP with the SYK inhibitor fostamatinib. ClinicalTrials.gov identifiers: NCT02076399, NCT02076412, and NCT02077192.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
| | - Ivy Altomare
- Duke University School of Medicine, Durham, NC, USA
| | - Mark R Thomas
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Vadim Markovtsov
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Leslie K Todd
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Esteban Masuda
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Medical College of Cornell University, 115 East 67th Street, New York, NY 10065, USA
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Pavord S, Thachil J, Hunt BJ, Murphy M, Lowe G, Laffan M, Makris M, Newland AC, Provan D, Grainger JD, Hill QA. Practical guidance for the management of adults with immune thrombocytopenia during the COVID-19 pandemic. Br J Haematol 2020; 189:1038-1043. [PMID: 32374026 PMCID: PMC7267627 DOI: 10.1111/bjh.16775] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/03/2020] [Indexed: 12/22/2022]
Abstract
This document aims to provide practical guidance for the assessment and management of patients with thrombocytopenia, with a particular focus on immune thrombocytopenia (ITP), during the COVID‐19 pandemic. The intention is to support clinicians and, although recommendations have been provided, it is not a formal guideline. Nor is there sufficient evidence base to conclude that alternative approaches to treatment are incorrect. Instead, it is a consensus written by clinicians with an interest in ITP or coagulation disorders and reviewed by members of the UK ITP forum.
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Affiliation(s)
- Sue Pavord
- Department of Haematology, Oxford University Hospitals, Oxford, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Foundation Trust, Manchester, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas' Hospital, London, UK
| | - Mike Murphy
- Department of Haematology, John Radcliffe Hospital, NHSBT, Oxford, UK
| | - Gillian Lowe
- Department of Haematology, University Hospitals of Birmingham, Birmingham, UK
| | - Mike Laffan
- Department of Haematology, Hammersmith Hospital, Du Cane Road, UK
| | - Mike Makris
- Department of Haematology, Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Adrian C Newland
- Department of Haematology, Barts and the London School of Medicine and Dentistry, London, UK
| | - Drew Provan
- Department of Haematology, Queen Mary University of London, Bart's and The London School of Medicine and Dentistry, Institute of Cell and Molecular Science, London, UK
| | - John D Grainger
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Quentin A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK
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Why do patients with immune thrombocytopenia (ITP) experience lower bleeding events despite thrombocytopenia? Thromb Res 2020; 187:154-158. [PMID: 32004875 DOI: 10.1016/j.thromres.2020.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia is an autoimmune condition characterized by an isolated thrombocytopenia. Despite the low platelet levels, severe bleeding episodes are relatively rare suggesting that patients with ITP may have a protective factor against bleeding. Platelet microparticles (PMP) are thought to play a role in clot formation and some studies have demonstrated higher levels of circulating PMP in patients with ITP. This article provides a review of the epidemiology, mechanism, clinical presentation, management, and prognosis of ITP as well as a review of the literature and discussion regarding PMP and bleeding risk in ITP patients.
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