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Ono R, Kitagawa I. SARS-CoV-2 infection-induced immune thrombocytopenia: a systematic review of current reports. Ann Hematol 2024:10.1007/s00277-024-05765-1. [PMID: 38652242 DOI: 10.1007/s00277-024-05765-1] [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: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count with increased risk of bleeding, and viral infection may trigger ITP. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-induced ITP has been increasingly reported. We systemically reviewed the previously reported cases of SARS-CoV-2 infection-induced ITP and identified a total of 105 patients from 68 studies. The median age was 61 years, and 14 patients (12%) were < 18 years old (pediatric cases). In adult cases, a total of 53% patients were classified as moderate to severe SARS-CoV-2 infection. The median platelet count at diagnosis and nadir were 6,000/µL and 4,000/µL, respectively. When comparing platelet levels between non-severe SARS-CoV-2 infection and moderate to severe SARS-CoV-2 infection, the median values of platelet levels at diagnosis were not significantly different between the groups (4,000/µL in non-severe SARS-CoV-2 infection and 9,000/µL in moderate to severe SARS-CoV-2 infection, p-value = 0.22). Median nadir platelet levels were also not significantly different between groups (4,000/µL in non-severe SARS-CoV-2 infection and 8,000/µL in moderate to severe SARS-CoV-2 infection, p-value = 0.27). More than half of the cases (53 patients) were treated with combination therapy including steroid, intravenous immunoglobulin, and eltrombopag. Major bleeding and intracranial hemorrhage occurred in ten (11%) and six (6.6%) cases, respectively. The overall mortality rate was 7%. In pediatric cases, none of the patients experienced major bleeding and lethal outcomes.
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Izumi Kitagawa
- Department of General Internal Medicine, Shonan Fujisawa Tokushukai Hospital, Japan, 1-5-1 Tsujido Kandai, Fujisawa, Kanagawa, 251-0041, Japan
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2
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Rasizadeh R, Ebrahimi F, Zamani Kermanshahi A, Daei Sorkhabi A, Sarkesh A, Sadri Nahand J, Bannazadeh Baghi H. Viruses and thrombocytopenia. Heliyon 2024; 10:e27844. [PMID: 38524607 PMCID: PMC10957440 DOI: 10.1016/j.heliyon.2024.e27844] [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: 09/19/2023] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Thrombocytopenia, characterized by a decrease in platelet count, is a multifaceted clinical manifestation that can arise from various underlying causes. This review delves into the intriguing nexus between viruses and thrombocytopenia, shedding light on intricate pathophysiological mechanisms and highlighting the pivotal role of platelets in viral infections. The review further navigates the landscape of thrombocytopenia in relation to specific viruses, and sheds light on the diverse mechanisms through which hepatitis C virus (HCV), measles virus, parvovirus B19, and other viral agents contribute to platelet depletion. As we gain deeper insights into these interactions, we move closer to elucidating potential therapeutic avenues and preventive strategies for managing thrombocytopenia in the context of viral infections.
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Affiliation(s)
- Reyhaneh Rasizadeh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Animal Biology, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran
| | - Fatemeh Ebrahimi
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Amin Daei Sorkhabi
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aila Sarkesh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javid Sadri Nahand
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Bannazadeh Baghi
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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3
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Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
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Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
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4
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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5
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Takehara T, Nishida H, Ichikawa K, Hosokawa Y, Nawano T, Takai S, Fukuhara H, Himuro M, Tsuchiya N, Watanabe M. Immune thrombocytopenia secondary to primary cytomegalovirus infection after renal transplantation treated with a thrombopoietin receptor agonist: a case report. BMC Nephrol 2023; 24:336. [PMID: 37957545 PMCID: PMC10644401 DOI: 10.1186/s12882-023-03385-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an acquired disorder characterised by a low platelet count due to immune-mediated destruction and impaired platelet production. Here we report a rare case of primary cytomegalovirus (CMV) infection followed by thrombocytopenia after renal transplantation (RT). CASE PRESENTATION A 24-year-old male patient with end-stage kidney disease secondary to hereditary focal segmental glomerulosclerosis was treated with peritoneal dialysis and received ABO-compatible living-related RT from his aunt. Nine months after the RT, the patient was diagnosed with primary CMV infection. After initiating treatment for primary CMV infection, the patient developed thrombocytopenia. After excluding other diseases or drugs that may cause thrombocytopenia, the patient was finally diagnosed with ITP, administered prednisolone (PSL), and started on Helicobacter pylori eradication therapy. Tapering the PSL dose was difficult, but thrombopoietin receptor agonists (TPO-RAs) were effective. CONCLUSIONS In this case, the patient was diagnosed with ITP, and other causes of thrombocytopenia after RT were successfully ruled out. This case report demonstrates that RT recipients can develop ITP after CMV infection, and, in such cases, TPO-RAs may be an attractive option as a second-line therapy.
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Affiliation(s)
- Tomohiro Takehara
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan.
| | - Hayato Nishida
- Department of Urology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Kazunobu Ichikawa
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Yuka Hosokawa
- Department of Internal Medicine III, Division of Hematology and Cell Therapy, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Takaaki Nawano
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Satoshi Takai
- Department of Urology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Hiroki Fukuhara
- Department of Urology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masahito Himuro
- Department of Internal Medicine III, Division of Hematology and Cell Therapy, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
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Sato K, Inoue J, Ninomiya M, Iwata T, Sano A, Tsuruoka M, Onuki M, Sawahashi S, Ouchi K, Masamune A. Effectiveness of tacrolimus in a case of immune checkpoint inhibitor-induced hepatotoxicity that was refractory to steroids and mycophenolate mofetil. Clin J Gastroenterol 2023; 16:720-725. [PMID: 37480423 DOI: 10.1007/s12328-023-01832-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
Immune checkpoint inhibitors (ICIs) sometimes induce immune-mediated hepatotoxicity (IMH), and corticosteroids and mycophenolate mofetil (MMF) are recommended for the treatment of IMH. However, there is no consensus on the treatment of IMH refractory to these drugs. Here, we report a case of refractory IMH that was successfully treated with tacrolimus. A 69-year-old man presented with liver injury after receiving durvalumab, an ICI, for lung cancer. He was diagnosed with IMH and received corticosteroids including methylprednisolone pulses and MMF, but his liver damage did not improve. Liver histology showed infiltration of inflammatory cells, mainly CD8 + T cells, in the portal area. Tacrolimus was added to corticosteroid and MMF to suppress mainly T cells. After the tacrolimus administration, the liver damage promptly improved. Since IMH is thought to be caused by activated CD8 + T-cell infiltration, T-cell suppression may be an effective treatment. This case suggests that tacrolimus may be an effective option for IMH refractory to corticosteroids or MMF if CD8 + T-cell infiltration is confirmed in the liver tissue.
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Affiliation(s)
- Kosuke Sato
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan.
| | - Masashi Ninomiya
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Tomoaki Iwata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Akitoshi Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Mio Tsuruoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Masazumi Onuki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Satoko Sawahashi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Keishi Ouchi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
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7
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Rosu VE, Roșu ST, Ivanov AV, Starcea IM, Streanga V, Miron IC, Mocanu A, Lupu A, Lupu VV, Gavrilovici C. Predictor Factors for Chronicity in Immune Thrombocytopenic Purpura in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:911. [PMID: 37371143 DOI: 10.3390/children10060911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/11/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023]
Abstract
(1) Background: Immune thrombocytopenia (ITP) is an acute autoimmune blood disorder that is the main cause of thrombocytopenia in children. It is characterized by a decrease in platelets below 100 × 109/L, and limited evolution with severe complications such as intracranial hemorrhage. The chronic form is defined by the persistence of thrombocytopenia more than 12 months after diagnosis. (2) Methods: We performed a retrospective study over a period of 10 years (1 January 2011-31 December 2020) at the Emergency Clinical Hospital for Children "Sf. Maria", Iasi. The aim of the study was to describe the clinical characteristics and to determine the prognostic factors in immune thrombocytopenia in children. (3) Results: In this study we included 271 children with ITP, comprising 123 females (45.4%) and 148 males (54.6%). The remission rate was higher in males, being 68.9% compared to 56.1% in females. Children with ITP under 9 years of age had a higher remission rate. Children with a platelet count > 10 × 109/L at diagnosis had a higher likelihood-of-remission rate compared to patients who presented initial platelet count below this value. (4) Conclusions: The risk factors highly suggestive for chronicity are: age at diagnosis, female sex, and the number of platelets at the onset of the disease.
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Affiliation(s)
- Vasile Eduard Rosu
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Solange Tamara Roșu
- Nursing, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Violeta Streanga
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Adriana Mocanu
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ancuta Lupu
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Gavrilovici
- Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
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8
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Ramey C, LePera A. A Possible Case of Nitrofurantoin-Associated Immune Thrombocytopenia in a Healthy 45-Year-Old Caucasian Female. Cureus 2023; 15:e34654. [PMID: 36895539 PMCID: PMC9991487 DOI: 10.7759/cureus.34654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2023] [Indexed: 02/07/2023] Open
Abstract
Patients presenting with immune thrombocytopenia (ITP) may have an associated underlying medical condition or medication exposure serving as the cause of their disease, but oftentimes, ITP is due to an idiopathic, autoimmune cause. While molecular mimicry is recognized as the pathogenesis behind infectious-related causes of ITP, drug-induced ITP is likely due to hapten formation, leading to an inappropriate immune-mediated response. Several drugs are associated with the development of ITP. Nitrofurantoin, a commonly prescribed antibiotic for the treatment of uncomplicated urinary tract infections (UTIs), is a medication not previously associated with the development of ITP, with only one case reporting the development of thrombotic thrombocytopenic purpura (TTP) after nitrofurantoin use. Herein, we report a case of a middle-aged Caucasian female with a history of anxiety and hypothyroidism who developed ITP following exposure to nitrofurantoin three weeks prior to presentation. The patient presented with signs and symptoms consistent with ITP: an isolated low platelet count of 1 x 109/L, petechia, fatigue, normal coagulation parameters, recurrent epistaxis, and melena. Subsequently, she was hospitalized for five days, receiving a total of four units of platelets during her stay. She was started on daily high-dose intravenous corticosteroids and received a one-time dose of intravenous immunoglobulin (IVIG). After achieving a platelet count greater than 30 x 109/L, she was discharged from inpatient care, having responded well to corticosteroid treatment. Upon follow-up with outpatient hematology, her platelet levels were maintained above 150 x 109/L, with full resolution of her acute illness. An autoimmune laboratory workup was negative except for an isolated, newly positive antinuclear antibody IgG with an elevated titer of 1:640, leading to the conclusion that an immunological response to nitrofurantoin had occurred. To our knowledge, this is the first report that describes an association between nitrofurantoin use and ITP. We hope this report aids clinicians in recognizing the various immune-mediated adverse reactions associated with nitrofurantoin.
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Affiliation(s)
- Caleb Ramey
- Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Alison LePera
- Emergency Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
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9
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Echcharii N, Chekhlabi N, Dini N. A Case of Cytomegalovirus Infection With Severe Thrombocytopenia in an Infant Who Was Successfully Managed With Antiviral Therapy. Cureus 2022; 14:e30640. [DOI: 10.7759/cureus.30640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
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10
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Autoimmune Encephalitis in COVID-19 Infection: Our Experience and Systematic Review of the Literature. Biomedicines 2022; 10:biomedicines10040774. [PMID: 35453524 PMCID: PMC9024859 DOI: 10.3390/biomedicines10040774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 01/08/2023] Open
Abstract
The neurologic complications of COVID-19 infection are frequent in hospitalized patients; a high percentage of them present neurologic manifestations at some point during the course of their disease. Headache, muscle pain, encephalopathy and dizziness are among the most common complications. Encephalitis is an inflammatory condition with many etiologies. There are several forms of encephalitis associated with antibodies against intracellular neuronal proteins, cell surfaces or synaptic proteins, referred to as autoimmune encephalitis. Several case reports published in the literature document autoimmune encephalitis cases triggered by COVID-19 infection. Our paper first presents our experience in this issue and then systematically reviews the literature on autoimmune encephalitis that developed in the background of SARS-CoV-2 infections and also discusses the possible pathophysiological mechanisms of auto-immune-mediated damage to the nervous system. This review contributes to improve the management and prognosis of COVID-19-related autoimmune encephalitis.
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Laali A, Kermanshah Z, Keyvani H, Kaveh V, Karampoor S. Idiopathic thrombocytopenic purpura as a hematologic manifestation of COVID-19 infection: A case report. Respir Med Case Rep 2021; 34:101534. [PMID: 34697584 PMCID: PMC8529288 DOI: 10.1016/j.rmcr.2021.101534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022] Open
Abstract
The hematologic system is one of the vulnerable parts of the human body in coronavirus disease-2019 (COVID-19) infection. Lymphopenia and disseminated intravascular coagulation (DIC) are among the most frequent consequences of COVID-19. Idiopathic thrombocytopenic purpura is one of the common causes of thrombocytopenia in adults. It is defined by thrombocytopenia when platelet counts <105/μl in the absence of anemia and leukopenia. Traditionally, infections, typically viral, have been known as the main culprits of low platelet counts before the involvement of ITP. According to the literature, C virus (HCV), HIV, varicella-zoster virus (VZV), and cytomegalovirus (CMV) are considered secondary causative agents for the development of ITP. In this study, we reported a case that was afflicted with concurrent severe thrombocytopenia diagnosed as ITP and COVID-19 infection.
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Affiliation(s)
- Azadeh Laali
- Department of Infectious Diseases, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Kermanshah
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Keyvani
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Virology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Kaveh
- Department of Hematology and Oncology, Iran University of Medical Sciences, Tehran, Iran
| | - Sajad Karampoor
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Virology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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12
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Ringoringo HP, Hartoyo E. Megadose Methylprednisolone for Immune Thrombocytopenia in an Infant Positive for SARS-CoV-2: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931517. [PMID: 34471086 PMCID: PMC8422568 DOI: 10.12659/ajcr.931517] [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] [Indexed: 11/16/2022]
Abstract
Patient: Male, 9-month-old
Final Diagnosis: Newly diagnosed ITP
Symptoms: Petechiae on the forehead • cheeks • mouth • extremities. The patient is febrile, had rhinorrhea for three days previously. The patient is pale, weak, cannot drink
Medication: —
Clinical Procedure: The patient had immunizations of the Measles-Rubella vaccine 19 days before. Physical examination: Eye, ENT, and mouth, no abnormalities. Heart and Lungs within normal limits. Abdomen: there was no organomegaly – there neither lymphadenopathy nor a congenital anomaly
Specialty: Hematology • Infectious Diseases • Pediatrics and Neonatology
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Affiliation(s)
- Harapan Parlindungan Ringoringo
- Department of Pediatrics, Faculty of Medicine, Lambung Mangkurat University, RSD Idaman Banjarbaru, Banjarbaru, South Kalimantan, Indonesia
| | - Edi Hartoyo
- Department of Pediatrics, Faculty of Medicine, Lambung Mangkurat University, Ulin General Hospital, Banjarmasin, South Kalimantan, Indonesia
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13
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Immune Thrombocytopenic Purpura in a Child with COVID-19: A Case Report. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2021. [DOI: 10.5812/pedinfect.110428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Introduction: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It may have many undescribed clinical manifestations. Case Presentation: In this study, we report a 7-year-old male COVID-19 patient with low platelet count who presented with gingival bleeding and ecchymosis and had a good response to corticosteroid therapy. Conclusions: This case highlights the need to be vigilant for atypical presentations or complications of COVID-19, one of which is SARS-CoV-2-induced immune thrombocytopenic purpura (ITP). It is necessary to pay attention to platelet count in addition to typical clinical features and radiographic findings. On the other hand, viral testing in thrombocytopenic patients should be considered for timely diagnosis of COVID-19 and taking necessary measurements for patient isolation in order to prevent the spread of disease and healthcare workers’ infection during this pandemic.
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14
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Moody R, Wilson K, Flanagan KL, Jaworowski A, Plebanski M. Adaptive Immunity and the Risk of Autoreactivity in COVID-19. Int J Mol Sci 2021; 22:ijms22168965. [PMID: 34445670 PMCID: PMC8396528 DOI: 10.3390/ijms22168965] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
While first and foremost considered a respiratory infection, COVID-19 can result in complications affecting multiple organs. Immune responses in COVID-19 can both protect against the disease as well as drive it. Insights into these responses, and specifically the targets being recognised by the immune system, are of vital importance in understanding the side effects of COVID-19 and associated pathologies. The body's adaptive immunity recognises and responds against specific targets (antigens) expressed by foreign pathogens, but not usually to target self-antigens. However, if the immune system becomes dysfunctional, adaptive immune cells can react to self-antigens, which can result in autoimmune disease. Viral infections are well reported to be associated with, or exacerbate, autoimmune diseases such as multiple sclerosis (MS) and systemic lupus erythematosus (SLE). In COVID-19 patients, both new onset MS and SLE, as well as the occurrence of other autoimmune-like pathologies, have been reported. Additionally, the presence of autoantibodies, both with and without known associations to autoimmune diseases, have been found. Herein we describe the mechanisms of virally induced autoimmunity and summarise some of the emerging reports on the autoimmune-like diseases and autoreactivity that is reported to be associated with SARS-CoV-2 infection.
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Affiliation(s)
- Rhiane Moody
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Kirsty Wilson
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Katie L. Flanagan
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS 7250, Australia
- School of Medicine, University of Tasmania, Launceston, TAS 7250, Australia
- Department of Immunology and Pathology, Monash University, Melbourne, VIC 3004, Australia
| | - Anthony Jaworowski
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Magdalena Plebanski
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
- Correspondence:
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15
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Smibert OC, Catalano OA, Goodarzi K, Roberts MB. Case 23-2021: A 41-Year-Old Woman with Bloody Stools and Thrombocytopenia. N Engl J Med 2021; 385:451-460. [PMID: 34320292 DOI: 10.1056/nejmcpc2103461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Olivia C Smibert
- From the Peter MacCallum Cancer Centre, Austin Health, and the University of Melbourne - all in Melbourne, VIC, Australia (O.C.S.); and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Massachusetts General Hospital, and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Harvard Medical School - both in Boston
| | - Onofrio A Catalano
- From the Peter MacCallum Cancer Centre, Austin Health, and the University of Melbourne - all in Melbourne, VIC, Australia (O.C.S.); and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Massachusetts General Hospital, and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Harvard Medical School - both in Boston
| | - Katayoon Goodarzi
- From the Peter MacCallum Cancer Centre, Austin Health, and the University of Melbourne - all in Melbourne, VIC, Australia (O.C.S.); and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Massachusetts General Hospital, and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Harvard Medical School - both in Boston
| | - Matthew B Roberts
- From the Peter MacCallum Cancer Centre, Austin Health, and the University of Melbourne - all in Melbourne, VIC, Australia (O.C.S.); and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Massachusetts General Hospital, and the Departments of Radiology (O.A.C.) and Medicine (K.G., M.B.R.), Harvard Medical School - both in Boston
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Abbasi F, Kaydani GA, Tahannezhad Z, Nakhaie M, Asnafi AA, Moradi M. Prevalence of Cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) Subclinical Infection in Patients with Acute Immune Thrombocytopenic Purpura (ITP). Int J Hematol Oncol Stem Cell Res 2021; 15:139-144. [PMID: 35082994 PMCID: PMC8748239 DOI: 10.18502/ijhoscr.v15i3.6843] [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: 12/24/2019] [Accepted: 06/28/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Farshad Abbasi
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Gholam Abbas Kaydani
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Department of Laboratory Sciences, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Zari Tahannezhad
- Department of Laboratory Sciences, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Nakhaie
- Department of Virology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Amin Asnafi
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Moradi
- Department of Biostatistics and Epidemiology, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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17
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Alonso-Beato R, Morales-Ortega A, Fernández FJDLH, Morón AIP, Ríos-Fernández R, Rubio JLC, Centeno NO. Immune thrombocytopenia and COVID-19: Case report and review of literature. Lupus 2021; 30:1515-1521. [PMID: 34053365 DOI: 10.1177/09612033211021161] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Immune thrombocytopenia, also known as immune thrombocytopenic purpura (ITP), has been reported as an important complication related to COVID-19.We present a 49-year-old male patient with systemic lupus erythematosus with lupus nephritis, antiphospholipid syndrome and history of ITP who developed an ITP flare in the context of COVID-19. He had no bleeding manifestations and had a good response to prednisone treatment.We review the characteristics of the cases reported to date in the literature, with an analysis of 57 patients. Mean age was 56 years (±19.6 SD), and 50.9% were male. This was the first episode of ITP in most of the patients (86.05%), with SARS-CoV-2 acting as the initial trigger. We found that ITP flares may appear in both mild and severe COVID-19 cases. They also appeared at any time during the course of the disease, 48.2% of patients developed it during hospitalization, while it was diagnosed at admission in the rest of the cases. Platelet counts were significantly lower than other ITP series, with a median nadir platelet count of 8 × 109/L (IQR 2-17.75 × 109/L). These patients show a higher bleeding rate (61.4%) compared with other ITP series. They also show a better response to treatment, with good response to the first line therapies in 76.9% of them. The most common first-line treatment was intravenous immunoglobulin (IVIG), used alone or combined with corticosteroids in 40.4% and 32.7% of cases respectively, while 25% of patients received only corticosteroids.Our review suggests that COVID-19-related ITP can be seen even in previously healthy patients. Clinicians must be aware that ITP may appear both in mild and severe COVID-19, at any time during its course. Given that this kind of ITP seems to be associated with a higher bleeding risk, its diagnosis in a clinical scenario such as COVID-19, where anticoagulant therapy is frequently used, may be critical. Treatment with IVIG and/or corticoids is often effective.
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Affiliation(s)
- Rubén Alonso-Beato
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | - Raquel Ríos-Fernández
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital, Universitario Clínico San Cecilio, Granada, Spain
| | - José Luis Callejas Rubio
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital, Universitario Clínico San Cecilio, Granada, Spain
| | - Norberto Ortego Centeno
- Faculty of Medicine, University of Granada, Granada, Spain
- Biomedical Research Institute Ibs, Granada, Granada
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18
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A Case of Epistaxis as the First Sign of Acute Idiopathic Thrombocytopenic Purpura. Case Rep Otolaryngol 2021; 2021:6612939. [PMID: 33628555 PMCID: PMC7884150 DOI: 10.1155/2021/6612939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/23/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is an acquired thrombocytopenia caused by the action of autoantibodies against platelet antigens. It is traditionally defined by a platelet count of less than 10 × 104/μL. Most patients with ITP are asymptomatic; however, symptoms have been confirmed in some cases. Conversely, it is very rare to find epistaxis as the first sign of ITP. We report the case of an 84-year-old man who came to the ear, nose, and throat department with severe and repeated epistaxis. We decided to keep him hospitalized as it was very difficult to stop the nasal bleeding. A full blood count showed a platelet level of only 1000/μL. Hematologic results confirmed the diagnosis of ITP. The patient underwent treatment with intravenous gamma-globulin, platelet transfusions, and romiplostim with a favorable response.
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19
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Michel M, Lega JC, Terriou L. [Secondary ITP in adults]. Rev Med Interne 2020; 42:50-57. [PMID: 33139079 DOI: 10.1016/j.revmed.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.
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Affiliation(s)
- M Michel
- Service de médecine interne, centre de référence pour les cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, université Paris Est Créteil, Assistance publique-Hôpitaux de Paris, Créteil, France.
| | - J-C Lega
- Service de médecine interne et vasculaire, centre de compétences cytopénies auto-immunes, hôpital Lyon Sud, Lyon, France
| | - L Terriou
- Département de médecine interne et immunologie clinique, CHU de Lille, Lille, France
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20
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Immune Thrombocytopenia in a Patient Recovering From COVID-19. Hemasphere 2020; 4:e419. [PMID: 33134859 PMCID: PMC7544261 DOI: 10.1097/hs9.0000000000000419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/19/2020] [Indexed: 12/28/2022] Open
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21
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Shragai T, Lebel E, Deshet D, Varon D, Avivi I, Kirgner I, Sarid N. Characteristics and outcomes of adults with cytomegalovirus‐associated thrombocytopenia: a case series and literature review. Br J Haematol 2020; 191:863-867. [DOI: 10.1111/bjh.17017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Tamir Shragai
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Eyal Lebel
- Department of Hematology Hadassah‐Hebrew University Medical Center Jerusalem Israel
| | - Dana Deshet
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Department of Hematology Edith Wolfson Medical Center Holon Israel
| | - David Varon
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Irit Avivi
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Ilya Kirgner
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Nadav Sarid
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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22
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Tsao HS, Chason HM, Fearon DM. Immune Thrombocytopenia (ITP) in a Pediatric Patient Positive for SARS-CoV-2. Pediatrics 2020; 146:peds.2020-1419. [PMID: 32439817 DOI: 10.1542/peds.2020-1419] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 11/24/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a potential presentation of COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral testing should be considered in these patients to allow for appropriate hospital triaging and isolation to limit community spread and health care worker infection during epidemics or pandemics. ITP is characterized by isolated thrombocytopenia. Approximately two-thirds of children with primary ITP have a history of a viral infection during the previous month.1,2 Viruses commonly identified as triggers include cytomegalovirus, hepatitis C, herpes, varicella zoster, Epstein-Barr, influenza, and HIV.3-7 In this case report, we describe the first documented case of a pediatric patient with ITP who tested positive for SARS-CoV-2. This case raises awareness of ITP as a possible pediatric presentation of coronavirus disease.
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Affiliation(s)
- Hoi See Tsao
- School of Public Health, .,Department of Emergency Medicine, and.,Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Deirdre M Fearon
- Department of Emergency Medicine, and.,Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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23
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Abstract
A 73-year-old female with past medical history of essential hypertension, hyperlipidemia, seasonal allergies, and chronic back pain presented to the hospital with complaints of headaches, fevers, fatigue, generalized body aches, shortness of breath, and diarrhea. Initial complete blood count was remarkable for leukopenia with an absolute lymph count of 0.60 K/µL and severe thrombocytopenia (platelet count < 3 K/µL). She was tested for COVID-19 via nasopharyngeal swab polymerase chain reaction (PCR) testing and found positive. Additional labs showed an elevated D-dimer, C-reactive protein, fibrinogen, and lactate dehydrogenase. Vitamin B12 and folate levels were obtained and found to be normal. Peripheral smear showed no schistocytes or additional hematologic abnormalities apart from thrombocytopenia. The patient was transfused one unit of platelets with no improvement in platelet count. Fibrinogen count was obtained and found in normal range at 458 mg/dL. Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) were all found to be normal. Immune thrombocytopenia purpura (ITP) was suspected and intravenous immunoglobulin (IVIG) was administered at a dose of 1 g/kg/day for two doses. By day 4, the patient had marked response to treatment with platelet recovery to 105 K/µL and subsequently discharged by day 5 with complete resolution of symptoms and platelet count of 146 K/µL. Twenty-eight days after discharge, she presented to hematology clinic with platelet count of 8 K/µL. Repeat nasopharyngeal swab PCR COVID testing was negative and she was treated with IVIG and pulse dexamethasone with prompt response, confirming suspicion of underlying, undiagnosed ITP prior to COVID infection.
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Affiliation(s)
- Joseph Bennett
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Christopher Brown
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Michael Rouse
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Marc Hoffmann
- Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, USA
| | - Zhan Ye
- Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, USA
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Yan M, Zhang Y, Yang F, Ji L, Wang M, Wang W. Comparative study between chronic immune thrombocytopenia patients and healthy population on Epstein-Barr virus infection status by polymerase chain reaction. Expert Rev Hematol 2020; 13:781-786. [PMID: 32498632 DOI: 10.1080/17474086.2020.1772746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) has been known to be associated with assorted virus infections. This study aims to investigate the Epstein-Barr virus infection status in chronic ITP patients by real-time quantitative polymerase chain reaction. METHODS 42 chronic ITP patients and 42 healthy donors were retrospectively included via propensity score matching with gender and age. EBV-DNA levels in whole blood of patients and donors were assessed by RT-qPCR, and correlations between virus load and platelet count were analyzed. RESULTS The positive rate of EBV-DNA in lymphocytes of chronic ITP patients was significantly higher than that in donors (52.4% vs 31.0%, p = 0.046). Platelet count [18(8-45)×109/L] of patients with high virus load in lymphocytes was significantly lower than that [51(30-87)×109/L] of patients with low virus load (p = 0.0001), whereas no difference was observed in platelet count between EBV-DNA-positive and negative subgroups of donors (p = 0.984). And a significant inverse correlation was observed between EBV-DNA levels in lymphocytes and platelet count (r = -0.4958, p = 0.019) in patients, which was independent from the presence of platelet-associated IgG. CONCLUSIONS EBV infection has a potential role in the development of chronic ITP. Identification and control of this underlying infection should be emphasized in the treatment of chronic ITP.
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Affiliation(s)
- Miao Yan
- Department of Hematology, Peking University First Hospital , Beijing, China
| | - Ying Zhang
- Department of Hematology, Peking University First Hospital , Beijing, China
| | - Fan Yang
- Department of Hematology, Peking University First Hospital , Beijing, China
| | - Li Ji
- Department of Hematology, Peking University First Hospital , Beijing, China
| | - Mangju Wang
- Department of Hematology, Peking University First Hospital , Beijing, China
| | - Wensheng Wang
- Department of Hematology, Peking University First Hospital , Beijing, China
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25
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Miltiadous O, Hou M, Bussel JB. Identifying and treating refractory ITP: difficulty in diagnosis and role of combination treatment. Blood 2020; 135:472-490. [PMID: 31756253 PMCID: PMC7484752 DOI: 10.1182/blood.2019003599] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/08/2019] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia after chemotherapy-induced thrombocytopenia. Existing guidelines describe the management and treatment of most patients who, overall, do well, even if they present with chronic disease, and they are usually not at a high risk for bleeding; however, a small percentage of patients is refractory and difficult to manage. Patients classified as refractory have a diagnosis that is not really ITP or have disease that is difficult to manage. ITP is a diagnosis of exclusion; no specific tests exist to confirm the diagnosis. Response to treatment is the only affirmative confirmation of diagnosis. However, refractory patients do not respond to front-line or other treatments; thus, no confirmation of diagnosis exists. The first section of this review carefully evaluates the diagnostic considerations in patients with refractory ITP. The second section describes combination treatment for refractory cases of ITP. The reported combinations are divided into the era before thrombopoietin (TPO) and rituximab and the current era. Current therapy appears to have increased effectiveness. However, the definition of refractory, if it includes insufficient response to TPO agents, describes a group with more severe and difficult-to-treat disease. The biology of refractory ITP is largely unexplored and includes oligoclonality, lymphocyte pumps, and other possibilities. Newer treatments, especially rapamycin, fostamatinib, FcRn, and BTK inhibitors, may be useful components of future therapy given their mechanisms of action; however, TPO agents, notwithstanding failure as monotherapy, appear to be critical components. In summary, refractory ITP is a complicated entity in which a precise specific diagnosis is as important as the development of effective combination treatments.
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Affiliation(s)
- Oriana Miltiadous
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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Ye L, Qian Y, Yu W, Guo G, Wang H, Xue X. Functional Profile of Human Cytomegalovirus Genes and Their Associated Diseases: A Review. Front Microbiol 2020; 11:2104. [PMID: 33013768 PMCID: PMC7498621 DOI: 10.3389/fmicb.2020.02104] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
The human cytomegalovirus (HCMV), whose genome is 235 ± 1.9 kbp long, is a common herpesvirus. However, the functions of many of its genes are still unknown. HCMV is closely associated with various human diseases and infects 60-90% of the global population. It can infect various human cells, including fibroblasts, epithelial cells, endothelial cells, smooth muscle cells, and monocytes. Although HCMV infection is generally asymptomatic and causes subtle clinical symptoms, it can generate a robust immune response and establish a latent infection in immunocompromised individuals, including those with AIDS, transplant recipients, and developing fetuses. Currently available antivirals approved for the treatment of HCMV-associated diseases are limited by dose-limiting toxicity and the emergence of resistance; however, vaccines and immunoglobulins are unavailable. In this review, we have summarized the recent literature on 43 newly identified HCMV genes. We have described their novel functions on the viral replication cycle, latency, and host immune evasion. Further, we have discussed HCMV-associated diseases and current therapeutic targets. Our review may provide a foundational basis for studies aiming to prevent and develop targeted therapies for HCMV-associated diseases.
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Affiliation(s)
- Lele Ye
- Department of Gynecologic Oncology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Microbiology and Immunology, Institute of Molecular Virology and Immunology, Institute of Tropical Medicine, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Yunyun Qian
- First Clinical College, Wenzhou Medical University, Wenzhou, China
| | - Weijie Yu
- First Clinical College, Wenzhou Medical University, Wenzhou, China
| | - Gangqiang Guo
- Department of Microbiology and Immunology, Institute of Molecular Virology and Immunology, Institute of Tropical Medicine, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Hong Wang
- Department of Microbiology and Immunology, Institute of Molecular Virology and Immunology, Institute of Tropical Medicine, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
- *Correspondence: Hong Wang, ; Xiangyang Xue,
| | - Xiangyang Xue
- Department of Microbiology and Immunology, Institute of Molecular Virology and Immunology, Institute of Tropical Medicine, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
- *Correspondence: Hong Wang, ; Xiangyang Xue,
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27
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Uemura S, Mori T, Nino N, Sakakibara N, Takafuji S, Myojin S, Takami Y, Morioka I, Nishimura N, Kugo M, Iijima K. An infant with refractory cytomegalovirus-induced thrombocytopenia. Clin Case Rep 2020; 8:75-78. [PMID: 31998491 PMCID: PMC6982504 DOI: 10.1002/ccr3.2581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/22/2019] [Accepted: 10/17/2019] [Indexed: 11/18/2022] Open
Abstract
The present case underscores the importance of considering the association of severe thrombocytopenia or immune thrombocytopenia with cytomegalovirus (CMV) infection because CMV-induced thrombocytopenia occasionally requires antiviral therapy.
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Affiliation(s)
- Suguru Uemura
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Takeshi Mori
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Nanako Nino
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Nana Sakakibara
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Satoru Takafuji
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Shota Myojin
- Department of PediatricsJapanese Red Cross Society Himeji HospitalHimejiJapan
| | - Yuichi Takami
- Department of PediatricsJapanese Red Cross Society Himeji HospitalHimejiJapan
| | - Ichiro Morioka
- Department of Pediatrics and Child HealthNihon University School of MedicineItabashi‐kuJapan
| | - Noriyuki Nishimura
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
| | - Masaaki Kugo
- Department of PediatricsJapanese Red Cross Society Himeji HospitalHimejiJapan
| | - Kazumoto Iijima
- Department of PediatricsKobe University Graduate School of MedicineKobeJapan
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A case of neonatal cytomegalovirus infection with severe thrombocytopenia that was successfully managed with empiric antiviral therapy. IDCases 2019; 19:e00675. [PMID: 32226764 PMCID: PMC7093750 DOI: 10.1016/j.idcr.2019.e00675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022] Open
Abstract
Antiviral therapy against cytomegalovirus (CMV) infection is indicated for symptomatic infection in the fetus and premature neonates. In mature neonates, the benefit of antiviral therapy for severe CMV infection remains controversial. Additionally, when diagnosing symptomatic CMV disease occurring during the early neonatal period, it is difficult to differentiate between congenital and acquired infections. We herein report a neonatal case of CMV infection complicated with severe thrombocytopenia that was successfully managed with antiviral treatment. A 21-day-old male infant presented with low-grade fever and erythema on his extremities. During outpatient follow-up, he developed petechiae and thrombocytopenia (platelet count 17,000/μL). Subsequent serological examination and molecular detection of CMV confirmed the diagnosis of CMV infection. In consideration of the severe thrombocytopenia, antiviral therapy with valganciclovir 32 mg/kg/day was initiated. The platelet counts increased with decreasing CMV loads. After excluding congenital CMV infection, we discontinued antiviral therapy without relapse of the disease. The present case suggests that neonatal cases of severe symptomatic CMV infection may require antiviral therapy while excluding the possibility of congenital infection.
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29
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Sohn SJ, Park KM, Yang EJ, Lim YT. Clinical Features and Treatment Outcomes of Immune Thrombocytopenic Purpura in Infants: A Single Center Retrospective Study. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2019. [DOI: 10.15264/cpho.2019.26.2.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sang Jun Sohn
- Department of Pediatrics, Pusan National University School of Medicines, Yangsan, Korea
| | - Kyung Mi Park
- Department of Pediatrics, Pusan National University School of Medicines, Yangsan, Korea
| | - Eu Jeen Yang
- Department of Pediatrics, Pusan National University School of Medicines, Yangsan, Korea
| | - Young Tak Lim
- Department of Pediatrics, Pusan National University School of Medicines, Yangsan, Korea
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30
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Bussel J, Miltiadous O. Immune Thrombocytopenia: Are We Stuck in the Mud or Is There Light at the End of the Tunnel? Clin Hematol Int 2019; 1:173-179. [PMID: 34595428 PMCID: PMC8432374 DOI: 10.2991/chi.d.190805.001] [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: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/17/2022] Open
Abstract
The differences in diagnosis and management between immune thrombocytopenia (ITP) and leukemia are striking. Leukemia diagnosis and management have evolved substantially over the past 30 years and are now relatively precise. The tendency for leukemic cells to be the overwhelming majority of circulating and/or bone marrow cells certainly continues to facilitate developments, as does improved molecular assessment. Furthermore, randomized controlled clinical trials of competing regimens in well-defined populations have advanced treatment as well. Currently, ITP diagnosis and management depend very much on the experience and preferences of the hematologist. There are no unequivocally useful molecular tests, no agreement on which testing needs to be performed, and no consensus on treatment. Future studies using advanced techniques would ideally change this over time but, thus far, progress in ITP has been slow. However, the increasing ability to do single-cell DNA and RNA studies and flow cytometric dissection of small populations of cells could radically change the approach to ITP if critical distinctions were uncovered.
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Affiliation(s)
- James Bussel
- Pediatrics, Division of Hematology-Oncology, Weill Cornell Medicine, New York, NY
| | - Oriana Miltiadous
- Pediatrics, Division of Hematology-Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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31
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Magdi M, Rahil A. Severe Immune Thrombocytopenia Complicated by Intracerebral Haemorrhage Associated with Coronavirus Infection: A Case Report and Literature Review. Eur J Case Rep Intern Med 2019; 6:001155. [PMID: 31410357 PMCID: PMC6663043 DOI: 10.12890/2019_001155] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 06/17/2019] [Indexed: 01/01/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune disorder that causes isolated thrombocytopenia. Many viruses have been identified as triggering the autoimmune process, including HIV, MCV, EBV, parvovirus, rubella and measles. However, ITP in association with coronavirus infection has not previously been reported. We describe the case of a healthy man who presented with severe ITP complicated by intracranial haemorrhage following upper respiratory tract infection. An infection screen revealed coronavirus infection.
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Affiliation(s)
| | - Ali Rahil
- Hamad Medical Corporation, Doha, Qatar
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32
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Karastaneva A, Klobassa DS, Minkov M, Benesch M, Seidel MG. Successful Treatment with SCIG of a Child with Refractory Chronic ITP. J Clin Immunol 2019; 39:19-22. [PMID: 30631990 DOI: 10.1007/s10875-018-0583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Anna Karastaneva
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Auenbruggerpl. 34/2, 8036, Graz, Austria. .,Divison of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria.
| | - Daniela S Klobassa
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Auenbruggerpl. 34/2, 8036, Graz, Austria.
| | - Milen Minkov
- Department of Pediatrics and Adolescent Medicine, Krankenhaus Rudolfstiftung, Vienna, Austria
| | - Martin Benesch
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Auenbruggerpl. 34/2, 8036, Graz, Austria.,Divison of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Auenbruggerpl. 34/2, 8036, Graz, Austria.,Divison of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
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33
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Thrombocytopenia in Infants: CMV-Related ITP or CMV-Related Thrombocytopenia? Indian J Hematol Blood Transfus 2018; 34:774-775. [DOI: 10.1007/s12288-018-0945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/03/2018] [Indexed: 11/25/2022] Open
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34
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Nishio Y, Kawano Y, Kawada JI, Ito Y, Hara S. A case of refractory cytomegalovirus-related thrombocytopenia that achieved complete remission without antiviral therapy. J Infect Chemother 2018; 24:995-997. [PMID: 30001843 DOI: 10.1016/j.jiac.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 05/19/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Cytomegalovirus (CMV) is one of the major infectious etiologies that induce thrombocytopenia. Although immune thrombocytopenic purpura (ITP) in children is often preceded by viral infections, thrombocytopenia associated with active CMV infection is considered CMV-related thrombocytopenia (CMV-thrombocytopenia), which can be distinguished from ITP. CMV-thrombocytopenia is reported to be less responsive to standard therapies for ITP and may require antiviral therapies. We herein report a case of refractory CMV-thrombocytopenia that achieved complete remission without antiviral therapy. A 20-month-old boy presented with a 2-day history of fever and systemic petechiae. There were no abnormal findings except for an extremely low platelet count (8000/μl) on blood examinations. He was clinically diagnosed with ITP, and intravenous immunoglobulin was administered twice, but his platelet count did not increase. CMV infection was suspected serologically, and a high CMV DNA load was detected in serum by real-time quantitative polymerase chain reaction (PCR). Without antiviral treatment, the CMV DNA load decreased below the detection limit on the 11th day of admission, followed by complete remission of the thrombocytopenia. The present case suggests that spontaneous recovery of thrombocytopenia can be expected in immunocompetent patients with CMV-thrombocytopenia in whom decreased CMV DNA load is observed.
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Affiliation(s)
- Yosuke Nishio
- Department of Pediatrics, TOYOTA Memorial Hospital, Japan.
| | | | - Jun-Ichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Japan
| | - Shinya Hara
- Department of Pediatrics, TOYOTA Memorial Hospital, Japan
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35
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Jin MJ, Kim Y, Choi EM, Shim YJ, Kim HS, Suh JK, Kim JY, Lee KS, Park SY, Lee JM, Hah JO. Clinical characteristics and treatment courses for cytomegalovirus-associated thrombocytopenia in immunocompetent children after neonatal period. Blood Res 2018; 53:110-116. [PMID: 29963516 PMCID: PMC6021578 DOI: 10.5045/br.2018.53.2.110] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/18/2017] [Accepted: 11/18/2017] [Indexed: 12/23/2022] Open
Abstract
Background Cytomegalovirus (CMV) causes severe diseases in premature infants and immunocompromised hosts, and antiviral therapy is often required for disease control. However, the clinical manifestations and treatment courses for CMV-associated thrombocytopenia in immunocompetent children are unclear. Methods Medical records of the children who suffered from thrombocytopenia, and showed positive CMV polymerase chain reaction and CMV-like symptoms were retrospectively analyzed at three university hospitals in Daegu from January 2000 to March 2017. Patients suffering from leukemia, immunodeficiency, and other infections were excluded. Results Among 1,065 children with thrombocytopenia, 29 (2.7%) displayed CMV-associated thrombocytopenia. The median age at diagnosis was 15 months and the median platelet count was 26,000/µL. They were classified into the CMV-induced thrombocytopenia (23/29) and CMV-related secondary immune thrombocytopenia (ITP, 6/29) groups. Fourteen subjects had hepatic dysfunction, four had Evans syndrome, two had pneumonitis, and one had gastritis. IVIG was used for 21 patients, and six patients among them showed recurrence, for whom IVIG or antiviral therapy was used. All, except one, recurrent or chronic cases belonged to the CMV-induced thrombocytopenia group. Antiviral therapy was used more frequently for the CMV-induced thrombocytopenia group (8/23, 34.8%) than for the CMV-related secondary ITP group (0/6); however, the results were not statistically significant (P=0.148). Conclusion CMV is a rare but unique etiology of thrombocytopenia, and observed even in healthy children after the neonatal period. About one-third patients need antiviral therapy for disease control. Further, CMV-induced thrombocytopenia is more complex than CMV-related secondary ITP.
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Affiliation(s)
- Min Ji Jin
- Department of Pediatrics, Keimyung University School of Medicine and Dongsan Medical Center, Daegu, Korea
| | - Yunkyum Kim
- Department of Pediatrics, Keimyung University School of Medicine and Dongsan Medical Center, Daegu, Korea
| | - Eun Mi Choi
- Department of Pediatrics, Keimyung University School of Medicine and Dongsan Medical Center, Daegu, Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine and Dongsan Medical Center, Daegu, Korea
| | - Heung Sik Kim
- Department of Pediatrics, Keimyung University School of Medicine and Dongsan Medical Center, Daegu, Korea
| | - Jin Kyung Suh
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Ji Yoon Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Kun Soo Lee
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Sun Young Park
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jeong Ok Hah
- Department of Pediatrics, Fatima Hospital, Daegu, Korea
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36
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Swinkels M, Rijkers M, Voorberg J, Vidarsson G, Leebeek FWG, Jansen AJG. Emerging Concepts in Immune Thrombocytopenia. Front Immunol 2018; 9:880. [PMID: 29760702 PMCID: PMC5937051 DOI: 10.3389/fimmu.2018.00880] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/09/2018] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease defined by low platelet counts which presents with an increased bleeding risk. Several genetic risk factors (e.g., polymorphisms in immunity-related genes) predispose to ITP. Autoantibodies and cytotoxic CD8+ T cells (Tc) mediate the anti-platelet response leading to thrombocytopenia. Both effector arms enhance platelet clearance through phagocytosis by splenic macrophages or dendritic cells and by induction of apoptosis. Meanwhile, platelet production is inhibited by CD8+ Tc targeting megakaryocytes in the bone marrow. CD4+ T helper cells are important for B cell differentiation into autoantibody secreting plasma cells. Regulatory Tc are essential to secure immune tolerance, and reduced levels have been implicated in the development of ITP. Both Fcγ-receptor-dependent and -independent pathways are involved in the etiology of ITP. In this review, we present a simplified model for the pathogenesis of ITP, in which exposure of platelet surface antigens and a loss of tolerance are required for development of chronic anti-platelet responses. We also suggest that infections may comprise an important trigger for the development of auto-immunity against platelets in ITP. Post-translational modification of autoantigens has been firmly implicated in the development of autoimmune disorders like rheumatoid arthritis and type 1 diabetes. Based on these findings, we propose that post-translational modifications of platelet antigens may also contribute to the pathogenesis of ITP.
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Affiliation(s)
- Maurice Swinkels
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maaike Rijkers
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Jan Voorberg
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands.,Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
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37
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Ozelo MC, Colella MP, de Paula EV, do Nascimento ACKV, Villaça PR, Bernardo WM. Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira - 2018. Hematol Transfus Cell Ther 2018; 40:50-74. [PMID: 30057974 PMCID: PMC6001928 DOI: 10.1016/j.htct.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | - Paula Ribeiro Villaça
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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38
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Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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39
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Sethi P, Treece J, Onweni C, Pai V, Arikapudi S, Kallur L, Kohli V, Moorman J. Acute Kidney Injury, Immune Thrombocytopenic Purpura, and the Infection That Binds Them Together: Disseminated Histoplasmosis. J Investig Med High Impact Case Rep 2017; 5:2324709617746193. [PMID: 29276711 PMCID: PMC5734493 DOI: 10.1177/2324709617746193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/06/2017] [Accepted: 11/11/2017] [Indexed: 11/17/2022] Open
Abstract
Untreated human immunodeficiency virus (HIV) can be complicated by opportunistic infections, including disseminated histoplasmosis (DH). Although endemic to portions of the United States and usually benign, DH can rarely act as an opportunistic infection in immunocompromised patients presenting with uncommon complications such as acute kidney injury and idiopathic thrombocytopenic purpura. We report a rare presentation of DH presenting with acute kidney injury and immune thrombocytopenic purpura in an immunocompromised patient with HIV.
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Affiliation(s)
- Pooja Sethi
- East Tennessee State University, Johnson City, TN, USA
| | | | | | - Vandana Pai
- East Tennessee State University, Johnson City, TN, USA
| | | | | | - Varun Kohli
- East Tennessee State University, Johnson City, TN, USA
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40
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Martinez AR, Paul MR, Kuo DJ. Treatment of immune thrombocytopenic purpura associated with cytomegalovirus infection in a child with pre-B cell acute lymphoblastic leukaemia after central nervous system relapse. BMJ Case Rep 2017; 2017:bcr-2017-221947. [PMID: 28947425 DOI: 10.1136/bcr-2017-221947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 13-year-old male patient with a history of pre-B cell acute lymphoblastic leukaemia (ALL) with isolated central nervous system relapse on maintenance chemotherapy presented with severe thrombocytopenia refractory to platelet transfusions. The patient showed only modest responses to two courses of intravenous immunoglobulin and steroids. He was found to be positive for cytomegalovirus (CMV) with modest viral load. His thrombocytopenia normalised with rituximab therapy and CMV treatment supporting the diagnosis of CMV-associated immune thrombocytopenic purpura (ITP). Following treatment, the patient continued to have a stable platelet count well above the threshold for transfusions. He continued to be intermittently treated for CMV when viral loads became detectable. This report discusses the unique management considerations of ITP in a patient undergoing therapy for ALL with a review of previously reported cases and discusses the possibility of CMV viraemia as a modulating factor.
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Affiliation(s)
- Ashley R Martinez
- Department of Pediatrics, University of California, San Diego, California, USA
| | - Megan Rose Paul
- Department of Pediatric Hematology-Oncology, University of California, San Diego, California, USA
| | - Dennis John Kuo
- Department of Pediatric Hematology-Oncology, University of California, San Diego, California, USA
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41
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Thompson RW, Gungor A. Immune thrombocytopenia of childhood responsive to tonsillectomy in the setting of chronic tonsillitis: A case report and literature review. Am J Otolaryngol 2017. [PMID: 28648251 DOI: 10.1016/j.amjoto.2016.11.002] [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
OBJECTIVES Immune thrombocytopenia of childhood (platelet count <100,000/μL) is the most common cause of thrombocytopenia in children. Patients typically present with bruising and bleeding in the setting of thrombocytopenia. Although it is usually short-lived, some cases persist and are unresponsive to treatment. This can lead to exposure to a variety of treatment regimens including immunosuppressants and splenectomy. The goal of this report is to present a case of chronic ITP of childhood that responded to tonsillectomy addressing the tonsils as a source of chronic infection and inflammation triggering ITP. METHODS A 4-year-old male with ITP of childhood presented with enlarged tonsils and obstructive sleep apnea. History and physical were consistent with chronic tonsillitis/adenoiditis including malaise, poor oral intake, congestion, rhinorrhea, tonsil hypertrophy, and lymphadenopathy persisting despite antibiotic therapy. Tonsillectomy and adenoidectomy were performed. RESULTS One, six, and eighteen weeks post-operatively the platelet count was 371, 215, and 205 respectively. Although at 12months two relapses had occurred, during the observed period, he had decreased incidence and severity of disease. CONCLUSION In around 60% of ITP there is a history of prior infection within the last month but no systemic symptoms at time of diagnosis. Additionally, chronic ITP is characterized by relapses coinciding with infection. This case is unique because the patient had chronic ITP and a clinical history and physical exam concerning for a subclinical, indolent inflammatory process that responded to surgical intervention. Given that chronic ITP exacerbation has been associated with recurrent acute infections it seems probable that chronic tonsillitis could serve as a trigger for relapse or contribute to a prolonged and/or more severe disease course. Therefore, tonsillectomy may result in earlier treatment and/or an altered disease course with avoidance of the expense and morbidity associated with frequent exacerbations and multiple treatment regimens.
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Affiliation(s)
- Richard William Thompson
- Lousiana State University Health-Shreveport, Department of Otolaryngology/Head and Neck Surgery-Pediatric ENT, Shreveport, LA, USA.
| | - Anil Gungor
- Lousiana State University Health-Shreveport, Department of Otolaryngology/Head and Neck Surgery-Pediatric ENT, Shreveport, LA, USA
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42
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Simpson JD, Matthews GV, Brighton TA, Joseph JE. Cytomegalovirus-associated thrombocytopenia treated with thrombopoietin receptor agonist. Intern Med J 2017; 46:1096-9. [PMID: 27633469 DOI: 10.1111/imj.13181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/30/2016] [Accepted: 06/16/2016] [Indexed: 11/27/2022]
Abstract
Symptomatic cytomegalovirus (CMV) in immunocompetent individuals is an uncommon, yet recognised, phenomenon. This report discusses a case of CMV-associated thrombocytopenia refractory to immunomodulation and antivirals. Ultimately, a clinicopathological response was attained with eltrombopag. This is the first report of the efficacy of thrombopoietin receptor agonists in this context. This experience provides insight into possible pathogenic mechanisms of CMV-associated thrombocytopenia and presents a therapeutic option.
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Affiliation(s)
- J D Simpson
- Departments of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
| | - G V Matthews
- Departments of Infectious Disease, St Vincent's Hospital, Sydney, New South Wales, Australia.,Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - T A Brighton
- Department of Haematology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - J E Joseph
- Departments of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
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43
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Segna D, Dufour JF. Other Extrahepatic Manifestations of Hepatitis C Virus Infection (Pulmonary, Idiopathic Thrombocytopenic Purpura, Nondiabetes Endocrine Disorders). Clin Liver Dis 2017; 21:607-629. [PMID: 28689597 DOI: 10.1016/j.cld.2017.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Extrahepatic manifestations of hepatitis C virus (HCV) infection are a rare but serious condition. This article summarizes the current literature on the association between HCV and endocrine and pulmonary manifestations, as well as idiopathic thrombocytopenic purpura (ITP). HCV may directly infect extrahepatic tissues and interact with the immune system predisposing for obstructive and interstitial lung disease, ITP, autoimmune thyroiditis, infertility, growth hormone and adrenal deficiencies, osteoporosis, and potentially lung and thyroid cancers. However, in many cases, the current evidence is divergent and cannot sufficiently confirm a true association, which emphasizes the need for future targeted projects in this field.
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Affiliation(s)
- Daniel Segna
- Department of General Internal Medicine, Inselspital - Bern University Hospital, Freiburgstrasse 4, Bern 3010, Switzerland; Division of Hepatology, Department of Visceral Surgery and Medicine, Inselspital- Bern University Hospital, Freiburgstrasse 4, Bern 3010, Switzerland
| | - Jean-François Dufour
- Division of Hepatology, Department of Visceral Surgery and Medicine, Inselspital- Bern University Hospital, Freiburgstrasse 4, Bern 3010, Switzerland.
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44
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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45
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46
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Zea-Vera AF, Parra B. Zika virus (ZIKV) infection related with immune thrombocytopenic purpura (ITP) exacerbation and antinuclear antibody positivity. Lupus 2016; 26:890-892. [PMID: 27694629 DOI: 10.1177/0961203316671816] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 30-year-old Colombian woman with past history of immune thrombocytopenia (ITP) presented to the emergency room with two days of global headache, arthralgia, myalgia, and low level fever and generalized erythematous rash. Platelets dropped to 9 × 109/L (fourth day of symptoms) without hemorrhagic manifestations but recovered to 30 × 109/L in 24 hours (fifth day). Dengue virus infection, as well as other viral infections, was ruled out. Zika virus (ZIKV) was evaluated in serum and urine samples by real-time reverse-transcriptase polymerase chain reaction (genomic regions within E protein and NS2b protein). Urine sample was positive and serum sample negative for ZIKV, confirming a recent ZIKV infection with urinary tract virus excretion at 7th day after disease onset. To our knowledge this is the first description of a case of severe immune thrombocytopenia exacerbation and antinuclear antibody positivity induced by ZIKV infection.
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Affiliation(s)
- A F Zea-Vera
- Microbiology Department, Health faculty, Universidad del Valle, Cali, Colombia
| | - B Parra
- Microbiology Department, Health faculty, Universidad del Valle, Cali, Colombia
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Elalfy MS, Nugent D. Viruses, anti-viral therapy, and viral vaccines in children with immune thrombocytopenia. Semin Hematol 2016; 53 Suppl 1:S70-2. [PMID: 27312173 DOI: 10.1053/j.seminhematol.2016.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Immune thrombocytopenia (ITP) might be preceded by silent or overt viral infections. Similarly, anti-viral drugs and viral vaccines could also trigger ITP and might play a central role in its pathogenesis. The seasonal nature of childhood ITP suggests that viral infections might initiate immune responses that increase the predisposition and occurrence of ITP. Active cytomegalovirus or Epstein-Barr virus should be considered in differential diagnosis when thrombocytopenia is associated with lymphadenopathy, especially with splenomegaly. This review will focus on the specific association of ITP in association with viral disease and vaccinations, and will discuss the effectiveness of current therapies in light of our current understanding of viral-associated ITP.
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Affiliation(s)
- Mohsen S Elalfy
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Diane Nugent
- CHOC Childrens Hospital, University of California Irvine, CA, USA
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Refractory Immune Thrombocytopenic Purpura and Cytomegalovirus Infection: A Call for a Change in the Current Guidelines. Mediterr J Hematol Infect Dis 2016; 8:e2016010. [PMID: 26740871 PMCID: PMC4696470 DOI: 10.4084/mjhid.2016.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/11/2015] [Indexed: 11/21/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is characterized by a decreased platelet count caused by excess destruction of platelets and inadequate platelet production. In many cases, the etiology is not known, but the viral illness is thought to play a role in the development of some cases of ITP. The current (2011) American Society of Hematology ITP guidelines recommend initial diagnostic studies to include testing for HIV and Hepatitis C. The guidelines suggest that initial treatment consist of observation, therapy with corticosteroids, IVIG or anti D. Most cases respond to the standard therapy such that the steroids may be tapered and the platelet counts remain at a hemostatically safe level. Some patients with ITP are dependent on long-term steroid maintenance, and the thrombocytopenia persists with the tapering of the steroids. Recent case reports demonstrate that ITP related to cytomegalovirus (CMV) can persist in spite of standard therapy and that antiviral therapy may be indicated. Herein we report a case of a 26-year-old female with persistent ITP that resolved after the delivery of a CMV-infected infant and placenta. Furthermore, we review the current literature on CMV-associated ITP and propose that the current ITP guidelines be amended to include assessment for CMV, even in the absence of signs and symptoms, as part of the work-up for severe and refractory ITP, especially prior to undergoing an invasive procedure such as splenectomy.
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Flores-Chang BS, Arias-Morales CE, Wadskier FG, Gupta S, Stoicea N. Immune Thrombocytopenic Purpura Secondary to Cytomegalovirus Infection: A Case Report. Front Med (Lausanne) 2015; 2:79. [PMID: 26579523 PMCID: PMC4630589 DOI: 10.3389/fmed.2015.00079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/20/2015] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
| | - Carlos E Arias-Morales
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Francis G Wadskier
- Department of Internal Medicine, St. Barnabas Hospital Bronx , Bronx, NY , USA
| | - Sorab Gupta
- Department of Internal Medicine, St. Barnabas Hospital Bronx , Bronx, NY , USA
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
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Glesner MK, Madsen KR, Nielsen JMR, Posth S. Successful emergency splenectomy during cardiac arrest due to cytomegalovirus-induced atraumatic splenic rupture. BMJ Case Rep 2015; 2015:bcr-2014-208094. [PMID: 25814026 DOI: 10.1136/bcr-2014-208094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old woman was admitted to the emergency department with fever and a petechial rash on suspicion of meningitis. Shortly after arriving she developed cardiac arrest. Blood work up showed severe lactate acidosis, anaemia and thrombocytopenia. A focused assessment with sonography in trauma scan showed free intraperitoneal fluid and an emergency laparotomy revealed massive bleeding from a ruptured spleen. The patient was successfully resuscitated. She proved to be infected with cytomegalovirus causing idiopathic thrombocytopenic purpura, splenomegaly and splenic rupture. She was treated for 14 days with ganciclovir and meropenem and discharged on recovery. Atraumatic splenic rupture caused by viral infection is a rare condition although well described. In the case of our patient, thrombocytopenia added to the severity of the splenic rupture. A multidisciplinary team approach was essential for the management and the eventual recovery of the patient.
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Affiliation(s)
| | | | | | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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