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Szaflarska A, Lenart M, Rutkowska-Zapała M, Siedlar M. Clinical and experimental treatment of primary humoral immunodeficiencies. Clin Exp Immunol 2024; 216:120-131. [PMID: 38306460 PMCID: PMC11036112 DOI: 10.1093/cei/uxae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/13/2023] [Accepted: 01/31/2024] [Indexed: 02/04/2024] Open
Abstract
Selective IgA deficiency (sIgAD), common variable immunodeficiency (CVID), and transient hypogammaglobulinemia of infancy (THI) are the most frequent forms of primary antibody deficiencies. Difficulties in initial diagnosis, especially in the early childhood, the familiar occurrence of these diseases, as well as the possibility of progression to each other suggest common cellular and molecular patomechanism and a similar genetic background. In this review, we discuss both similarities and differences of these three humoral immunodeficiencies, focusing on current and novel therapeutic approaches. We summarize immunoglobulin substitution, antibiotic prophylaxis, treatment of autoimmune diseases, and other common complications, i.e. cytopenias, gastrointestinal complications, and granulomatous disease. We discuss novel therapeutic approaches such as allogenic stem cell transplantation and therapies targeting-specific proteins, dependent on the patient's genetic defect. The diversity of possible therapeutics models results from a great heterogeneity of the disease variants, implying the need of personalized medicine approach as a future of primary humoral immunodeficiencies treatment.
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Affiliation(s)
- Anna Szaflarska
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Marzena Lenart
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Magdalena Rutkowska-Zapała
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Maciej Siedlar
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
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Somasundaram N, Meyer O, Scheibenbogen C, Hanitsch LG, Stittrich A, Kölsch U, Wittke K. Clinical and immunological characterisation of patients with common variable immunodeficiency related immune thrombocytopenia. Clin Exp Med 2023; 23:5423-5432. [PMID: 37670184 PMCID: PMC10725337 DOI: 10.1007/s10238-023-01166-2] [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: 04/06/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023]
Abstract
Primary Immune thrombocytopenia (ITP) is an autoimmune disease. Secondary ITP occurs in patients with underlying diseases such as common variable immunodeficiency (CVID). CVID is one of the most common symptomatic primary immunodeficiencies in adults, characterised by infectious and non-infectious symptoms. Amongst CVID patients, ITP is the most frequent autoimmune manifestation. In this single-centre study, we performed a clinical and immunological characterisation of 20 patients with CVID-related ITP and 20 ITP patients without CVID to compare severity and remission rates. We found that patients with CVID-related ITP had a higher WHO Bleeding Scale at initial diagnosis yet showed higher remission rates and required less treatment. Patients with ITP needed up to seven therapy options and were often treated with second-line drug therapy, whilst only one CVID-related ITP patient required second-line drug therapy. Therefore, we show that the course of thrombocytopenia in patients with CVID-related ITP is milder. Furthermore, we show that soluble interleukin-2 receptor (sIL-2R, CD25) was higher in CVID-related ITP compared to ITP patients and could accurately classify patient cohorts with an Area Under the Receiver Operating Characteristic of 0.92. Whilst none of the ITP patients had a history of immunodeficiency, we found immunological abnormalities in 12 out of 18 patients. Therefore, we recommend screening ITP patients for CVID and other immunodeficiencies to detect immune abnormalities early, as we found patients with reduced immunoglobulin levels as well as severe lymphocytopenia in our ITP cohort.
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Affiliation(s)
- Nadia Somasundaram
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Immunology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Oliver Meyer
- Red Cross Blood Service NSTOB, Eldagsener Straße 38, 31832, Springe, Germany
| | - Carmen Scheibenbogen
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Immunology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Leif Gunnar Hanitsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Immunology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anna Stittrich
- Labor Berlin - Charité Vivantes GmbH, Sylter Str. 2, 13353, Berlin, Germany
| | - Uwe Kölsch
- Labor Berlin - Charité Vivantes GmbH, Sylter Str. 2, 13353, Berlin, Germany
| | - Kirsten Wittke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Immunology, Augustenburger Platz 1, 13353, Berlin, Germany.
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Alzahrani TS, Al-Jabri H, Elhomoudi A. Unusual phenotype of heterozygous LOF mutation in IKZF1, with common variable immunodeficiency presenting initially as immune thrombocytopenia: A case report. J Paediatr Child Health 2022; 58:2308-2311. [PMID: 35979904 DOI: 10.1111/jpc.16162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Talal S Alzahrani
- Department of Pediatric Oncology, King Faisal Specialist Hospital and Research Centre, Medina, Saudi Arabia
| | - Hassan Al-Jabri
- Department of Pediatrics, King Salman bin Abdulaziz Medical City, Medina, Saudi Arabia
| | - Ayman Elhomoudi
- Department of Pediatric Oncology, King Faisal Specialist Hospital and Research Centre, Medina, Saudi Arabia
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[Splenectomy for the treatment of common variable immunodeficiency complicated with cytopenia: report of one case and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:846-850. [PMID: 34788925 PMCID: PMC8607021 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To improve the understanding of splenectomy for treating common variable immunodeficiency complicated with cytopenia. Methods: A case of common variable immunodeficiency complicated with cytopenia was reported, and the literature was reviewed. Results: The patient, female, 16 years old, was hospitalized for eight years due to thrombocytopenia; she manifested recurrent thrombocytopenia with leukopenia since adolescence. The patient was diagnosed with common variable immunodeficiency with repeated mild infections, splenomegaly, and significantly reduced plasma immunoglobulin levels. Additionally, splenectomy was performed with adequate immunoglobulin replacement therapy, and the pathology confirmed hypersplenism; her blood cell level returned to normal after surgery. Conclusions: Common variable immunodeficiency has various clinical manifestations and can be complicated with cytopenia. Under the premise of adequate immunoglobulin replacement therapy, splenectomy is a safe and effective treatment for common variable immunodeficiency in patients with recurrent cytopenia.
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Saettini F, Cattoni A, Redaelli M, Silvestri D, Ferrari GM, Biondi A, Jankovic M, Spinelli M. Primary immunodeficiencies, autoimmune hyperthyroidism, coeliac disease and systemic lupus erythematosus in childhood immune thrombocytopenia. Acta Paediatr 2021; 110:643-651. [PMID: 33025591 DOI: 10.1111/apa.15593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/26/2020] [Accepted: 09/21/2020] [Indexed: 01/05/2023]
Abstract
AIM To evaluate the cumulative prevalence of coeliac disease, systemic lupus erythematosus, autoimmune hyperthyroidism and primary immunodeficiencies in children with either newly diagnosed/persistent or chronic immune thrombocytopenia (ITP). METHODS Monocentric retrospective analysis of the clinical and biochemical features of 330 consecutive patients with ITP referred to our Pediatric Hematology Unit between January 2009 and December 2018. RESULTS The prevalence of systemic lupus erythematosus (0.3%), coeliac disease (0.3%) and autoimmune hyperthyroidism (0.6%) was not increased compared to general paediatric population. Of note, the prevalence of underlying primary immunodeficiencies was 2.4%, remarkably higher than the general paediatric population (P = .005). All the patients diagnosed with immunodeficiency developed either bi-/trilinear cytopenia or splenomegaly. CONCLUSION Whilst autoimmune and immunological screening is already recommended at the onset of immune thrombocytopenia, we recommend that primary immunodeficiencies be regularly screened during follow-up, especially in case of additional cytopenia or lymphoproliferation.
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Affiliation(s)
- Francesco Saettini
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Alessandro Cattoni
- Department of Pediatrics San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Martina Redaelli
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Daniela Silvestri
- Department of Pediatrics San Gerardo Hospital Fondazione TettamantiUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Giulia Maria Ferrari
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Andrea Biondi
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
- Department of Pediatrics San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Momcilo Jankovic
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
| | - Marco Spinelli
- Department of Pediatric Onco‐Hematology San Gerardo Hospital Fondazione MBBMUniversità degli Studi di Milano‐Bicocca Monza Italy
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Mohtashami M, Razavi A, Abolhassani H, Aghamohammadi A, Yazdani R. Primary Immunodeficiency and Thrombocytopenia. Int Rev Immunol 2021; 41:135-159. [PMID: 33464134 DOI: 10.1080/08830185.2020.1868454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Primary immunodeficiency (PID) or Inborn errors of immunity (IEI) refers to a heterogeneous group of disorders characterized by immune system impairment. Although patients with IEI manifest highly variable symptoms, the most common clinical manifestations are recurrent infections, autoimmunity and malignancies. Some patients present hematological abnormality including thrombocytopenia due to different pathogenic mechanisms. This review focuses on primary and secondary thrombocytopenia as a complication, which can occur in IEI. Based on the International Union of Immunological Societies phenotypic classification for IEI, the several innate and adaptive immunodeficiency disorders can lead to thrombocytopenia. This review, for the first time, describes manifestation, mechanism and therapeutic modalities for thrombocytopenia in different classes of IEI.
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Affiliation(s)
- Maryam Mohtashami
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.,Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadehsadat Razavi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Department of Animal Biology, Faculty of Biology Sciences, University of Kharazmi, Tehran, Iran.,Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
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Dilley M, Wangberg H, Noone J, Geng B. Primary immunodeficiency diseases treated with immunoglobulin and associated comorbidities. Allergy Asthma Proc 2021; 42:78-86. [PMID: 33404391 DOI: 10.2500/aap.2021.42.200113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Primary immunodeficiency diseases (PIDD) consist of a heterogeneous group of disorders characterized by various aspects of immune dysregulation. Although the most universally recognized manifestation of PIDD is an increased susceptibility to infections, there is a growing body of evidence that patients with PIDD often have a higher incidence of lung disease, autoimmunity, autoinflammatory disorders, and malignancy. Objective: The purpose of this study was to better understand the noninfectious complications of PIDD by determining the comorbid disease prevalence across various age groups, genders, and immunoglobulin replacement types compared with the general population. Methods: A large U.S. insurance claims database was retrospectively analyzed for patients who had a diagnosis of PIDD and who had received intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin (SCIG). The prevalences of 31 different comorbid conditions in the Elixhauser comorbidity index were compared among the 3125 patients in the PIDD population to > 37 million controls separated by gender and by 10-year age cohorts. Results: In the PIDD population, statistically significantly higher comorbid diagnoses included chronic obstructive pulmonary disease-asthma in 51.5%, rheumatoid disease in 14%, deficiency anemia in 11.8%, hypothyroidism in 21.2%, lymphoma in 16.7%, neurologic disorders in 9.7%, arrhythmias in 19.9%, electrolyte disorders in 23.6%, coagulopathies in 16.9%, and weight loss in 8.4%. Conclusion: PIDD that require immunoglobulin replacement are associated with an increased risk of numerous comorbid conditions that affect morbidity and mortality. Recognition and increased awareness of these noninfectious complications can allow for better monitoring, care coordination, targeted treatments, and improved prognosis.
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Affiliation(s)
- Michelle Dilley
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
| | - Hannah Wangberg
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
| | - Joshua Noone
- Department of Public Health Sciences, University of North Carolina, Charlotte, North Carolina
| | - Bob Geng
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
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8
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Nepesov S, Aygun F, Firtina S, Cokugras H, Camcioglu Y. Clinical and immunological features of 44 common variable immunodeficiency patients: the experience of a single center in Turkey. Allergol Immunopathol (Madr) 2020; 48:675-685. [PMID: 32299645 DOI: 10.1016/j.aller.2019.12.008] [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: 09/15/2019] [Revised: 11/29/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Common variable immunodeficiency (CVID) is one of the most prevalent forms of primary immunodeficiency characterized by hypogammaglobinemia. Its heterogeneous clinical features include recurrent respiratory tract infections and other complications such as gastrointestinal, autoimmunity, and lymphoproliferative disorders. The aim of this article is to evaluate the general characteristics of CVID patients. MATERIALS AND METHODS Clinical and immunological features of 44 CVID patients were evaluated retrospectively with long-term follow-up. Patients who participated in the study were diagnosed according to the criteria of the European Society for Immunodeficiency Diseases (ESID). RESULTS The median age at onset of symptoms was 2.75 years (range 6 months to 17 years), and the median age at diagnosis was 7.75 years (range 4-20 years). The average delay in diagnosis was 4.6 years (range 1-14 years). Positive family history was 18.2%. Before treatment, patients' median total serum IgG was 271.5mg/dL, median IgA was 7.5mg/dL, and median IgM was 21mg/dL. Infections were the most common clinical manifestation, and 63.6% of patients presented with sinopulmonary infection as the first manifestation. Bronchiectasis developed in 23 CVID subjects, while bronchiectasis was detected prior to CVID diagnosis in eight patients. All patients received immunoglobulin replacement therapy, and one patient died because of granulomatous lymphocytic interstitial lung disease (GLILD). CONCLUSIONS CVID is a heterogeneous group of immunologic disorders with unknown etiology. There are significant differences in the clinical presentation and prevalence of CVID-related complications among countries. Local guidelines for diagnosis and clinical follow-up are needed.
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Cowen JE, Stevenson J, Paravasthu M, Darroch J, Jacob A, Tueger S, Gosney JR, Simons A, Spencer LG, Judge EP. Common variable immunodeficiency with granulomatous-lymphocytic interstitial lung disease and preceding neurological involvement: a case-report. BMC Pulm Med 2020; 20:205. [PMID: 32736614 PMCID: PMC7393898 DOI: 10.1186/s12890-020-01231-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
Background Common variable immunodeficiency (CVID) is a group of heterogeneous primary immunodeficiencies characterised by a dysregulated and impaired immune response. In addition to an increased susceptibility to infection, it is also associated with noninfectious autoimmune and lymphoproliferative complications. CVID is rarely associated with neurological complications. Pulmonary involvement is more common, and patients can develop an interstitial lung disease known as granulomatous-lymphocytic interstitial lung disease (GLILD). Case presentation A 50-year-old Caucasian female with a history of Evans syndrome (idiopathic thrombocytopaenic purpura and autoimmune haemolytic anaemia) and hypogammaglobulinaemia initially presented to the neurology clinic with marked cerebellar ataxia and headaches. Following extensive investigation (which included brain biopsy), she was diagnosed with neuro-sarcoidosis and her symptoms resolved following treatment with immunosuppressive therapy. Over the following 10 years, she was extensively investigated for recurrent pulmonary infections and abnormal radiological findings, which included pulmonary nodules, infiltrates and splenomegaly. Subsequently, she was referred to an immunology clinic, where immunoglobulin replacement treatment was started for what was ultimately considered to be CVID. Shortly afterwards, evaluation of her clinical, radiological and histological findings at a specialist interstitial lung disease clinic led to a diagnosis of GLILD. Conclusion CVID is a condition which should be suspected in patients with immunodeficiency and recurrent infections. Concomitant autoimmune disorders such as haemolytic anaemia and immune thrombocytopenia may further support the diagnosis. As illustrated in this case, there is a rare association between CVID and inflammatory involvement of the neurological system. Respiratory physicians should also suspect CVID with associated GLILD in patients with apparent pulmonary granulomatous disease and recurrent infections. In addition, this case also highlights the challenge of diagnosing CVID and its associated features, and how the definitive exclusion of other pathologies such as malignancy, mycobacterial infection and lymphoma is required as part of this diagnostic process.
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Affiliation(s)
- Jake E Cowen
- Department of Respiratory Medicine, Aintree Chest Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK.
| | - James Stevenson
- Department of Pathology, Whiston Hospital, St Helen's & Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
| | - Madhusudan Paravasthu
- Department of Radiology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - James Darroch
- Department of Immunology, Royal Liverpool & Broadgreen Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Anu Jacob
- Department of Neurology, The Walton Centre, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Salaheddin Tueger
- Department of Haematology, Countess of Chester Hospital, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - John R Gosney
- Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Anneliese Simons
- Department of Respiratory Medicine, Aintree Chest Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
| | - Lisa G Spencer
- Department of Respiratory Medicine, Aintree Chest Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
| | - Eoin P Judge
- Department of Respiratory Medicine, Aintree Chest Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
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Thadchanamoorthy V, Dayasiri K. Dengue hemorrhagic fever as a rare cause of chronic immune thrombocytopenic purpura-a pediatric case report. Trop Med Health 2020; 48:59. [PMID: 32699523 PMCID: PMC7370471 DOI: 10.1186/s41182-020-00248-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022] Open
Abstract
Background Dengue is a common mosquito-borne infection in tropical countries. Dengue incidence in Sri Lanka is generally showing a rising trend. Both chronic immune thrombocytopenia purpura (ITP) children and chronic ITP triggered by dengue fever in the pediatric age group are rarely reported. This unusual presentation is a diagnostic challenge to clinicians. The authors have reported a pediatric patient who presented with chronic ITP following recovery from dengue hemorrhagic fever. Case presentation A 14-year-old previously healthy boy was initially managed as for dengue hemorrhagic fever. Following initial detection of persistent thrombocytopenia at 2 weeks post-discharge, his parents defaulted follow-up for 1 year as he remained asymptomatic. However, 1 year after initial admission, the child re-presented with ecchymotic patches and a platelet count of 30 × 103/cumm. Review of serial blood counts performed during previous hospital admission and by his parents themselves revealed persistent thrombocytopenia over preceding 12 months. Subsequently, the child had an in-depth evaluation. The diagnosis of ITP was confirmed by ruling out differential diagnosis and he was managed as for chronic ITP. His platelet counts showed good response to oral corticosteroids and he is currently being followed up at the pediatric hematology clinic. Conclusion While reporting, a 14-year-old boy who developed chronic ITP following dengue hemorrhagic fever, this report highlights importance of frequent monitoring of blood counts to accurately detect and manage critical phase of dengue fever. The report also highlights the value of monitoring platelet counts in post-recovery phase to ensure they have normalized.
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Affiliation(s)
- V Thadchanamoorthy
- Faculty of Health Care Sciences, Eastern University, Chenkalady, Sri Lanka
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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: 92] [Impact Index Per Article: 23.0] [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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Lacombe V, Lozac'h P, Orvain C, Lavigne C, Miot C, Pellier I, Urbanski G. [Treatment of ITP and AIHA in CVID: A systematic literature review]. Rev Med Interne 2019; 40:491-500. [PMID: 31101329 DOI: 10.1016/j.revmed.2019.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/11/2019] [Accepted: 02/24/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ten to 15% of common variable immunodeficiencies (CVID) develop auto-immune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Treatment is based on immunosuppressants, which produce blocking effects in the CVID. Our objective was to assess their risk-benefit ratio in these immunocompromised patients. METHODS We identified 17 articles detailing the treatment of AIHA and/or ITP in patients suffering from CVID through a systematic review of the MEDLINE database. RESULTS The increased infectious risk with corticosteroids does not call into question their place in the first line of treatment of ITP and AIHA in CVID. High-doses immunoglobulin therapy remain reserved for ITP with a high risk of bleeding. In second-line treatment, rituximab appears to be effective, with a lower infectious risk than the splenectomy. Immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclophosphamide, vincristine, ciclosporine) are moderately effective and often lead to severe infections, meaning that their use is justified only in resistant cases and steroid-sparing. Dapsone, danazol and anti-D immunoglobulins have an unfavorable risk-benefit ratio. The place of TPO receptor agonists is still to be defined. The establishment of immunoglobulin replacement in the place of immunosuppressants (except for short-term corticotherapy) or splenectomy appears to be essential to limit the risk of infections, including in the absence of previous infections. CONCLUSION The presence of CVID does not mean that it is necessary to give up on corticosteroids as a first-line treatment and rituximab as a second-line treatment for AIHA and ITP, but it should be in addition to immunoglobulin replacement. A splenectomy should be reserved as a third-line treatment.
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Affiliation(s)
- V Lacombe
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P Lozac'h
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Orvain
- Service des maladies du sang, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Lavigne
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France
| | - C Miot
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Laboratoire d'immunologie et allergologie, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - I Pellier
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - G Urbanski
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France.
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Autoimmunity and infection in common variable immunodeficiency (CVID). Autoimmun Rev 2016; 15:877-82. [PMID: 27392505 DOI: 10.1016/j.autrev.2016.07.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 06/05/2016] [Indexed: 11/23/2022]
Abstract
Common variable immunodeficiency (CVID) is a heterogeneous group of diseases, characterized by primary hypogammaglobulinemia. B and T cell abnormalities have been described in CVID. Typical clinical features of CVID are recurrent airway infections; lymphoproliferative, autoinflammatory, or neoplastic disorders; and autoimmune diseases among which autoimmune thrombocytopenia (ITP) is the most common. The coexistence of immunodeficiency and autoimmunity appears paradoxical, since one represents a hypoimmune state and the other a hyperimmune state. Considering both innate and adaptive immune response abnormalities in CVID, it is easier to understand the mechanisms that lead to a breakdown of self-tolerance. CD21(low) B cells derive from mature B cells that have undergone chronic immune stimulation; they are increased in CVID patients. The expansion of CD21(low) B cells is also observed in certain autoimmune diseases. We have studied CD21(low) B cells in patients with CVID, CVID, and ITP and with ITP only. We observed a statistically significant increase in the CD21(low) population in the three pathological groups. Moreover, we found statistical differences between the two groups of CVID patients: patients with ITP had a higher percentage of CD21(low) cells. Our data suggest that CD21(low) cells are related to autoimmunity and may represent a link between infection and autoimmunity.
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