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David P, Santos GDM, Patt YS, Orsi FA, Shoenfeld Y. Immune thrombocytopenia (ITP) - could it be part of autoimmune/inflammatory syndrome induced by adjuvants (ASIA)? Autoimmun Rev 2024; 23:103605. [PMID: 39182594 DOI: 10.1016/j.autrev.2024.103605] [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: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 08/27/2024]
Abstract
Immune thrombocytopenia (ITP) is a complex autoimmune disorder characterized by thrombocytopenia and an increased bleeding risk, arising from autoantibody-mediated platelet destruction and impaired megakaryocyte function. The pathogenesis of ITP involves a multifaceted interplay of genetic predispositions, immune dysregulation, and environmental triggers, though the precise mechanisms remain uncertain. Several infectious agents, mostly viruses, have been implicated in both acute and chronic ITP through mechanisms such as molecular mimicry, direct bone marrow suppression, and immune dysregulation. Vaccinations, particularly those containing adjuvants like aluminum and those capable of inducing molecular mimicry, have also been associated with ITP, either as a new onset or as a relapse in preexisting cases. The role of drugs, particularly quinine, quinidine and certain antibiotics, in inducing ITP through various immunological pathways further illustrates the diverse etiologies of this condition. The multiple triggers of the disease raise the question of whether ITP may be classified as an autoimmune/inflammatory syndrome induced by adjuvants (ASIA). This condition encompasses a range of autoimmune and inflammatory symptoms triggered by adjuvants, such as silicones, polypropylene meshes, metal implants, and mineral oils present in various medical materials and medications. Similar to that observed in some cases of ITP, adjuvants can trigger autoimmune or autoinflammatory responses via molecular mimicry, epitope spreading, and polyclonal activation. This narrative review explores the underlying environmental factors related to ITP and examines ITP triggers that could potentially support an association between ITP and ASIA syndrome.
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Affiliation(s)
- Paula David
- Internal Medicine B, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Leeds Institute of Rheumatic and Musculoskeletal Diseases (LIRMM), University of Leeds, Leeds, UK.
| | - Gabrielle de Mello Santos
- Hospital das Clinicas of University of São Paulo Medical School (HCFMUSP), São Paulo, Brazil; HEMORIO - State Institute of Hematology "Arthur de Siqueira Cavalcanti", Rio de Janeiro, Brazil
| | - Yonatan Shneor Patt
- Internal Medicine B, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Fernanda A Orsi
- Hospital das Clinicas of University of São Paulo Medical School (HCFMUSP), São Paulo, Brazil; Department of Pathology, School of Medical Sciences of the University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Yehuda Shoenfeld
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Reichman University, Herzliya, Israel
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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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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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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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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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Furuhata M, Yanagisawa N, Nishiki S, Sasaki S, Suganuma A, Imamura A, Ajisawa A. Severe Thrombocytopenia and Acute Cytomegalovirus Colitis during Primary Human Immunodeficiency Virus Infection. Intern Med 2016; 55:3671-3674. [PMID: 27980271 PMCID: PMC5283971 DOI: 10.2169/internalmedicine.55.7169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We herein report the case of a 25-year-old man who was referred to our hospital due to acute cytomegalovirus (CMV) colitis. The initial blood tests showed that the patient had concurrent primary human immunodeficiency virus (HIV) infection and severe thrombocytopenia. Raltegravir-based antiretroviral therapy (ART) was initiated without the use of ganciclovir or corticosteroids and resulted in a rapid clinical improvement. Platelet transfusions were only necessary for a short period, and subsequent colonoscopy revealed a completely healed ulcer. This case implies that ART alone could be effective for treating severe thrombocytopenia during primary HIV and CMV coinfection.
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Affiliation(s)
- Masanori Furuhata
- Department of Infectious Diseases, Tokyo Metropolitan Komagome Hospital, Japan
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