Lenalidomide-Associated ITP

Navigating the Nexus: Lenalidomide-Associated Thrombotic Thrombocytopenic Purpura

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy (TMA) marked by thrombocytopenia, microangiopathic hemolytic anemia, and microvascular thrombosis leading to end-organ damage. While TTP commonly results from hereditary or acquired ADAMTS13 deficiency, its association with lenalidomide is notably rare. The link between lenalidomide and TMA is unclear and requires more studies, given the high mortality risk associated with TTP. The underlying mechanism may involve immunomodulatory effects leading to ADAMTS13 inhibitory antibody formation. Herein, we present a case of a 56-year-old male with a history of multiple myeloma status post autologous stem cell transplant, on lenalidomide maintenance therapy for over five years, who presented with progressive weakness, jaundice, palpitations, and paraesthesia in his extremities. On arrival, the patient was afebrile and was neurologically intact except for the subjective paraesthesia. He was found to have critically low ADAMTS13 activity at <0.03 IU/mL and detectable ADAMTS13 inhibitors, with other findings of TTP, requiring discontinuation of lenalidomide, in addition to receiving treatment for this life-threatening TMA.

Suspected Immune Thrombocytopenic Purpura Induced by Lenalidomide for the Treatment of Myelodysplastic Syndrome with Deletion of Chromosome 5q: A Case Report

Lenalidomide (LEN), one of the key drugs in the treatment of myelodysplastic syndromes (MDS) with 5q deletion, as well as multiple myeloma (MM), has various immunomodulatory effects and has been associated with autoimmune diseases, including immune thrombocytopenic purpura (ITP). A 78-year-old man presented with pancytopenia and was diagnosed with MDS with 5q deletion and other chromosomal abnormalities. Two cycles of LEN therapy (one cycle: 10 mg/day for 21 days) resulted in a transient improvement in anemia, followed by MDS progression with severe thrombocytopenia (4 × 10⁹/L) refractory to platelet transfusions. As other non-immune and alloimmune causes of transfusion-refractory thrombocytopenia were excluded, and the level of platelet-associated immunoglobulin G was extremely high compared with the level before treatment with LEN, the diagnosis of ITP was highly suspected. Despite treatment with prednisolone (PSL), eltrombopag, and repeated platelet transfusions, his platelet count did not increase, and he died of a gastrointestinal hemorrhage. Several cases of ITP induced by LEN used to treat MM had been reported, but the platelet count recovered after administration of PSL in these previous cases. However, we should be mindful of using LEN for patients with MDS because its treatment may become extremely difficult if ITP develops.

Lenalidomide-Associated Immune Thrombocytopenia: A Case Report and Review of the Literature

Lenalidomide is indicated in the front-line management of multiple myeloma. More recently, it has been introduced for use in treating other hematologic malignancies. Although the drug is known to cause myelosuppression, there have been rare reports of lenalidomide-associated immune thrombocytopenia (ITP). Here, we review the literature on lenalidomide-associated ITP and report upon a 59-year-old man who was administered lenalidomide due to concern of progressive multiple myeloma more than a year following his having undergone an autologous hematopoietic stem cell transplant. His platelet count precipitously declined and lead to his hospitalization. Despite our withholding of the drug, he did not respond to platelet transfusions or administration of corticosteroids. He was successfully managed with intermittent immune globulin for several months before definitive treatment with splenectomy, which resulted in the complete resolution of his thrombocytopenia. A literature search identified a total of six additional cases of lenalidomide-associated ITP. Similarly, many of the reported cases were associated with persistent thrombocytopenia after discontinuation of the drug. Furthermore, these patients were generally managed successfully with standard ITP therapies, such as corticosteroids or intravenous immune globulin.