Role of Helicobacter pylori Eradication Therapy on Platelet Recovery in Chronic Immune Thrombocytopenic Purpura

Case report: A case of immune thrombocytopenia combined with Hashimoto's thyroiditis and Helicobacter pylori infection in a child

Immune thrombocytopenia (ITP) is one of the most prevalent acquired bleeding disorders in children, which is primarily characterized by a decrease in platelet count. It can be classified into two subtypes: primary ITP and secondary ITP. The underlying mechanisms causing ITP are complex and not fully comprehended. Helicobacter pylori (H. pylori) infections can lead to ITP and potentially trigger various autoimmune diseases. Furthermore, there is evidence of a correlation between thyroid disease and ITP. In this case report, we describe the case of an 11-year-old patient who presented with ITP, Hashimoto's thyroiditis (HT), and H. pylori infection. Following anti-H. pylori treatment and thyroxine supplementation, the child's platelet count increased compared to the previous count. The limitation of this report is that the platelet count of this child returned to normal after anti-H. pylori and thyroxine supplementation, so we cannot distinguish the effect of anti-H. pylori and thyroxine supplementation on the platelet count in this child. Despite this limitation, we still believe that early screening for thyroid function and H. pylori, as well as prompt eradication of H. pylori, along with thyroxine supplementation, may be beneficial in treating and improving the prognosis of children diagnosed with ITP.

Role of Long non Coding RNAs, NEAT1 and Lnc-DC Expression in Pediatric Immune Thrombocytopenic Purpura

Background

Pediatric immune thrombocytopenic purpura (ITP) is an autoimmune disease; whose etiology is unknown. lncRNAs are regulators of numerous actions, which participate in the development of autoimmune diseases. We evaluated the expression ofNEAT1 and Lnc-RNA in dendritic cell (Lnc-DC) in pediatric ITP.

Methods

Sixty ITP patients and 60 healthy subjects were enrolled in the present study; Real-time PCR was performed to assess the expression levels of NEAT1 and Lnc-DC in sera of children with ITP as well as healthy children.

Results

Both lncRNAs, NEAT1 and Lnc-DC were significantly upregulated in ITP patients in comparison to controls (p <0.0001 and P= 0.001 respectively). Furthermore, significant upregulation of the expression levels of NEAT1 and Lnc-DC were observed in the non-chronic compared with chronic ITP patients. Also, there was significant negative correlation between each of NEAT1 and Lnc-DC and platelet counts before treatment (r= -0.38; P= 0.003 and r= -0.461; P< 0.0001, respectively).

Conclusions

serum lncRNAs, NEAT1 and Lnc-DC could be used as potential biomarkers in differentiating childhood ITP patients and healthy controls in addition to differentiating non-chronic from chronic ITP which may provide a theoretical basis for the mechanism and treatment of immune thrombocytopenia.

Helicobacter pylori-Related Extraintestinal Manifestations—Myth or Reality

It is well documented that Helicobacter pylori (H. pylori) can cause both gastrointestinal and extraintestinal manifestations. The latter one represents a major burden in terms of diagnosis and treatment. H. pylori-associated systemic subclinical inflammation is mostly responsible for the development of extraintestinal manifestations, and its early eradication might result in preventing all adverse events related to their occurrence. Thus, it was suggested that H. pylori might be associated with iron deficiency anemia, thrombocytopenia (immune thrombocytopenic purpura), Schonlein Henoch purpura, failure to thrive, vitamin B12 deficiency, diabetes mellitus, body mass index, cardiovascular diseases, as well as certain neurological conditions. Nevertheless, studies showed both pros and cons in terms of the role of H. pylori in the development of previously mentioned clinical entity underlining the crucial need for further studies on these topics. Although most of these extraintestinal manifestations occur during adulthood, we must not forget that H. pylori infection is acquired mainly during childhood, and thus its early diagnosis and eradication might represent the cornerstone in the prevention of H. pylori-induced inflammatory status and consequently of all related extraintestinal conditions.

Old and New Aspects of H. pylori-Associated Inflammation and Gastric Cancer

H. pylori is involved in the development of 80% of gastric cancers and 5.5% of all malignant conditions worldwide. Its persistence within the host’s stomach causes chronic inflammation, which is a well-known hallmark of carcinogenesis. A wide range of cytokines was reported to be involved in the initiation and long-term persistence of this local and systemic inflammation. IL-8 was among the first cytokines described to be increased in patients with H. pylori infection. Although, this cytokine was initially identified to exert a chemoattracting effect that represents a trigger for the activation of inflammatory cells within H.-pylori-infected mucosa, more recent studies failed in encountering any association between IL-8 and H. pylori infection. IL-6 is a multifunctional, pleiotropic and multipotent cytokine involved in mediating the interaction between innate and adaptive immunity with a dichotomous role acting as both a proinflammatory and an anti-inflammatory cytokine depending on the signaling pathway. IL-1α functions as a promoter of angiogenesis and vascular endothelial cell proliferation in gastric carcinoma since it is closely related to H.-pylori-induced inflammation in children. IL-1β is an essential trigger and enhancer of inflammation. The association between a low IL-1β level and an increased TNF-α level might be considered a risk factor for peptic ulcer disease in the setting of H. pylori infection. IL-10 downregulates both cytotoxic inflammatory responses and cell-mediated immune responses. H. pylori uses the immunosuppressive role of IL-10 to favor its escape from the host’s immune system. TGFβ is a continuous inflammatory mediator that promotes the adherence of H. pylori to the host’s cells and their subsequent colonization. The role of H.-pylori-induced inflammatory responses in the onset of gastric carcinogenesis seems to represent the missing puzzle piece for designing effective preventive and therapeutic strategies in patients with H.-pylori-associated gastric cancer.

Helicobacter Pylori and Autoimmune Diseases: Involving Multiple Systems

The modern Gastroenterology have witnessed an essential stride since Helicobacter pylori was first found in the stomach and then its pathogenic effect was discovered. According to the researches conducted during the nearly 40 years, it has been found that this bacterium is associated with a natural history of many upper gastrointestinal diseases. Epidemiological data show an increased incidence of autoimmune disorders with or after infection with specific microorganisms. The researches have revealed that H. pylori is a potential trigger of gastric autoimmunity, and it may be associated with other autoimmune diseases, both innate and acquired. This paper reviews the current support or opposition about H. pylori as the role of potential triggers of autoimmune diseases, including inflammatory bowel disease, autoimmune thyroiditis, type 1 diabetes mellitus, autoimmune liver diseases, rheumatoid arthritis, idiopathic thrombocytopenic purpura, systemic lupus erythematosus, as well as Sjogren’s syndrome, chronic urticaria and psoriasis, and tried to explain the possible mechanisms.

Helicobacter pylori induced Immune Thrombocytopenic Purpura and perspective role of Helicobacter pylori eradication therapy for treating Immune Thrombocytopenic Purpura

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterised by production of autoantibodies against platelet surface antigens. Recent studies have demonstrated a paramount association of ITP and Helicobacter pylori (H-pylori) infection with significant rise in platelet count following H-pylori eradication therapy. The H-pylori infection induced ITP is validated by many proposed mechanisms such as molecular mimicry due to production of autoantibodies against H-pylori surface virulent factors (CagA) and cross reactivity of these antibodies with platelet surface antigens (GP IIb/IIIa, GP Ib/IX, and GP Ia/IIa), phagocytic perturbation due to enhanced phagocytic activity of monocytes, enhanced dendritic cell numbers and response, platelets aggregation due to presence of anti- H-pylori IgG and von Willebrand factor (vWf) and finally host immune response against H-pylori virulent factors CagA and VacA leading to ITP. The effectiveness of H-pylori eradication therapy has also been demonstrated with platelet count being used as a predictive factor for assessment of treatment efficacy. Out of 201 patients 118 were responding to the triple therapy and remaining 83 patients were non-responders, showing the response rate of 58.7%. Out of 118 responders 69 patients were showing complete response (CR) and 49 were showing partial response (PR) to the H-pylori eradication therapy. However, more studies are required to elucidate this association and treatment efficacy.

Effect of Helicobacter Pylori eradication on patients with ITP: a meta-analysis of studies conducted in the Middle East

Background

Immune thrombocytopenia (ITP) is a bleeding disorder. Helicobacter pylori is a Gram-negative bacterium that is presumed to be associated with ITP and therapeutic response of patients. To evaluate the effect of H. pylori eradication on platelet count of ITP patients, we analyzed the studies conducted on the association between H. pylori infection and response to therapy in ITP patients in Western Asia focusing on the Middle East region.

Methods

A systematic search of databases (PubMed/Medline, ISI Web of Science, Cochrane Central) and Google Scholar search engine results was conducted up until January 2020. The keywords included in the search were Helicobacter pylori and/or H. pylori, ITP and/or immune thrombocytopenia.

Results

Seven studies comprising a total of 228 H. pylori-infected patients (193 with successful eradication) were included in this study. The association between H. pylori eradication and ITP was expressed as odds ratios (OR) and 95% confidence intervals (CI). The findings showed that patients who received eradication treatment for H. pylori infection had significantly higher OR (OR, 8.83; 95% CI, 2.03‒38.35; P=0.004) than those in the non-eradicated group.

Conclusion

Our results indicate a significant therapeutic effect of H. pylori eradication on the platelet count of patients with chronic ITP. Given the inherent limitations of this study, including the small number of patients, further studies with more patients are recommended.

Update on diagnosis and treatment of immune thrombocytopenia

BACKGROUND

Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP.

AREA COVERED

This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'.

EXPERT OPINION

We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.

Pediatric gastritis and its impact on hematologic parameters

Non-invasive biomarkers, such as neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios, may predict inflammation in various disorders, including gastritis, according to recent data. Nevertheless, various studies reported an association between Helicobacter pylori (H pylori) and immune thrombocytopenia in both adults and pediatric patients. The objective of our study was to evaluate the impact of pediatric gastritis, caused or not by H pylori infection on erythrocytes, their parameters, thrombocytes, mean platelet volume, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR).We performed a prospective, case-control study on 151 patients aged between 1 and 17 years who presented with chronic dyspeptic symptoms. An upper digestive endoscopy with gastric biopsies and a complete blood count was performed in each case.Control group consisted of 67 patients with normal histological findings, while the two study groups were divided into group 1-H pylori-induced gastritis (31 patients) and group 2-non-H pylori-induced gastritis (53 patients). Children from the rural area were more likely to develop both types of gastritis (P < .01). No significant difference was found between either of the study groups and control group in terms of platelets, mean platelet volume, NLR and PLR (P > .05). However, significantly higher values of lymphocytes were associated with non-H pylori-induced gastritis (P < .01). Comparison of the two study groups did not reflect any significant differences in terms of hematological parameters. When assessing these constants in relation to gastritis severity, severe gastritis led to a compelling decrease in hemoglobin (Hb) and hematocrit (Htc) levels. The comparison of parameters between severe, moderate, and mild gastritis did not reveal any significant results.Childhood and adolescent gastritis does not produce a significant effect upon platelet counts, their mean volume, PLR or NLR, according to our study. An important increase in lymphocyte count might predict non-H pylori pediatric gastritis. Moreover, severe gastritis might result in an important decrease in Hb and Htc levels.

Serum cytokines and clinical features in patients with fever and thrombocytopenia syndrome

PURPOSE

To explore the clinical, microbiological and immunological features of patients with fever and thrombocytopenia.

METHODS

Patients with unexplained fever and thrombocytopenia were enrolled. Viruses were detected using real-time PCR, and bacteria were measured by culturing methods. Serum cytokines, platelet antibody IgG (PA-IgG) and Helicobacter pylori (HP) were detected using ELISA.

RESULTS

Pathogens were detected in 74.68% of patients, which included single fungal/viral/bacterial infection and multiple infection. The pathogens could not be unidentified in 25.32% of cases. Cytokines including Interleukin (IL)-6, IL-10, interferon-γ(IFN-γ), platelet activating factor (PAF) and PA-IgG were significantly higher in patients as compared to healthy controls (P < .01 or P < .05). Principal component analyses extracted four groups of parameters that have a strong positive predicting value, revealing that disease status evaluation would be more accurate if we combined the platelet parameters and inflammatory biomarkers. While event-free survival (EFS) that indicates the time of platelet elevated after therapy was the highest in patients with single bacterial or fungal infection, EFS was affected by the levels of cytokines and PA-IgG.

CONCLUSIONS

Differences in immune function may be the main factors affecting the prognosis of patients with fever and thrombocytopenia, while treatment based on precise etiological diagnosis is important for therapeutic efficacy.