Dural Venous Sinus Thrombosis and Pulmonary Embolism Following Immunoglobulin Treatment in Pediatric Patient With Immune Thrombocytopenic Purpura

Primary Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenic Purpura

Introduction

Immune thrombocytopenic purpura is an autoimmune hematological disorder characterized by low platelet level due to its destruction through autoimmune antibodies. Cerebral venous thrombosis is a serious condition defined by a thrombosis in the cerebral venous sinuses that occurs mostly in the presence of a hypercoagulable state. Hemorrhage and thrombosis are processes with a paradoxical etiology; thus, the association between these two conditions seems to be extremely rare. Case Presentation. We herein report a case of a 19-year-old female with a chief compliant of generalized tonic-clonic episode, severe headache, and blurred vision. Physical examination was significant for a bilateral Babinski's sign and severe bilateral papilledema. Laboratory workup, computed tomography, and magnetic resonance imaging were normal except for severe thrombocytopenia. Magnetic resonance venography was diagnostic for cerebral venous thrombosis. Her past medical history was significant for immune thrombocytopenic purpura that was treated with prednisolone 40 mg per day which posed a therapeutic challenge. High-dose prednisolone and platelet transfusion were initiated; enoxaparin was administrated and switched to warfarin after stabilization of platelet count. The patient was neurologically intact after 14 days of appropriate treatment and was on follow-up. Many hypotheses were suggested to explain the unexpected thrombotic events in a patient with immune thrombocytopenic purpura which were related to the disease etiology or treatment, taking into account common risk factors (such as age, obesity, smoking, hypertension, diabetes mellitus, dyslipidemia, splenectomy, and oral contraceptive agents).

Conclusion

The association between immune thrombocytopenic purpura (which is a major risk factor for bleeding) and cerebral venous thrombosis ( which is caused by a thromboembolic event )has carried a major challenge to the management plan. We believe that immune thrombocytopenic purpura and its treatment methods should be taken into consideration as risk factors for thromboembolic phenomenon.

Immune Thrombocytopenic Purpura as a Hemorrhagic Versus Thrombotic Disease: An Updated Insight into Pathophysiological Mechanisms

Immune thrombocytopenic purpura (ITP) is a blood disorder characterized by a low platelet count of (less than 100 × 109/L). ITP is an organ-specific autoimmune disease in which the platelets and their precursors become targets of a dysfunctional immune system. This interaction leads to a decrease in platelet number and, subsequently, to a bleeding disorder that can become clinically significant with hemorrhages in skin, on the mucous membrane, or even intracranial hemorrhagic events. If ITP was initially considered a hemorrhagic disease, more recent studies suggest that ITP has an increased risk of thrombosis. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The autoimmune response in ITP involves both the innate and adaptive immune systems, comprising both humoral and cell-mediated immune responses. Thrombosis in ITP is related to the pathophysiology of the disease (young hyperactive platelets, platelets microparticles, rebalanced hemostasis, complement activation, endothelial activation, antiphospholipid antibodies, and inhibition of natural anticoagulants), ITP treatment, and other comorbidities that altogether contribute to the occurrence of thrombosis. Physicians need to be vigilant in the early diagnosis of thrombotic events and then institute proper treatment (antiaggregant, anticoagulant) along with ITP-targeted therapy. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The accumulated evidence has identified multiple pathophysiological mechanisms with specific genetic predispositions, particularly associated with environmental conditions.

Adverse Effects of Immunoglobulin Therapy

Immunoglobulin has been widely used in a variety of diseases, including primary and secondary immunodeficiency diseases, neuromuscular diseases, and Kawasaki disease. Although a large number of clinical trials have demonstrated that immunoglobulin is effective and well tolerated, various adverse effects have been reported. The majority of these events, such as flushing, headache, malaise, fever, chills, fatigue and lethargy, are transient and mild. However, some rare side effects, including renal impairment, thrombosis, arrhythmia, aseptic meningitis, hemolytic anemia, and transfusion-related acute lung injury (TRALI), are serious. These adverse effects are associated with specific immunoglobulin preparations and individual differences. Performing an early assessment of risk factors, infusing at a slow rate, premedicating, and switching from intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG) can minimize these adverse effects. Adverse effects are rarely disabling or fatal, treatment mainly involves supportive measures, and the majority of affected patients have a good prognosis.