Clinical Dilemmas in Immune Thrombocytopenic Purpura With Diffuse Alveolar Hemorrhage: Diagnosis, Treatment, and Outcomes

This report elucidates a unique case of a 39-year-old female with immune thrombocytopenic purpura (ITP) who developed a rare and severe complication: diffuse alveolar hemorrhage (DAH). Despite initial treatments for ITP, the patient experienced fluctuating platelet (PLT) counts and shortness of breath, which were later identified as symptoms of DAH. An urgent splenectomy improved the patient's platelet counts and overall condition. This case underscores the imperative to recognize DAH as a possible ITP complication, requiring clinicians' vigilance for prompt diagnosis and intervention. The intricate nature of ITP in adults necessitates individualized, patient-centered treatment approaches to enhance outcomes. This report provides invaluable insights into the clinical understanding and management of ITP and its complications through detailed analysis and documentation of the patient's treatment journey.

Dengue Infection Triggering Concurrent Thrombotic Thrombocytopenic Purpura in a Case of Chronic Idiopathic Thrombocytopenic Purpura

We present a case report detailing the medical history of a 53-year-old female who had a well-established 10-year history of idiopathic thrombocytopenic purpura (ITP). The patient presented with fever and gum bleeding, prompting a series of laboratory investigations. These examinations revealed concurrent thrombocytopenia and hemolytic anemia, alongside a positive test result for serum dengue IgM antibodies. Initial treatment for the patient involved intravenous administration of glucocorticoids and intravenous immunoglobulin. Regrettably, this therapeutic intervention did not yield a favorable response. Subsequent clinical developments, including the onset of generalized tonic-clonic seizures, raised suspicions of thrombotic thrombocytopenic purpura (TTP). A notable diagnostic indicator was the elevated PLASMIC score (platelet count; combined hemolysis variable; absence of active cancer; absence of stem-cell or solid-organ transplant; mean corpuscular volume; international normalized ratio; creatinine), reinforcing the consideration of TTP. To confirm the diagnosis, ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin motifs 13) enzyme levels were assessed and found to be low. Consequently, the patient was diagnosed with TTP. Plasmapheresis was administered, resulting in a positive clinical response after two cycles. Notably, the patient experienced a resolution of thrombocytopenia and hemolytic anemia. Following successful treatment, the patient was discharged with a prescription for immunosuppressants. This case underscores the critical importance of including TTP as a potential differential diagnosis when encountering patients with chronic ITP. TTP is characterized by its acute and life-threatening nature, often deviating from the typical clinical presentation. The application of the PLASMIC score serves as a valuable tool in guiding decision-making processes when TTP is suspected.

Immune thrombocytopenic purpura secondary to COVID-19 vaccination: A systematic review

INTRODUCTION

This systematic review aimed to retrieve patients diagnosed with de novo immune thrombocytopenic purpura (ITP) after COVID-19 immunization to determine their epidemiological characteristics, clinical course, therapeutic strategies, and outcome.

MATERIALS AND METHODS

We conducted the review using four major databases, comprising PubMed, Scopus, Web of Science, and the Cochrane library, until April 2022. A systematic search was performed in duplicate to access eligible articles in English. Furthermore, a manual search was applied to the chosen papers' references to enhance the search sensitivity. Data were extracted and analyzed with the SPSS 20.1 software.

RESULTS

A total of 77 patients with de novo COVID-19 vaccine-associated ITP were identified from 41 studies, including 31 case reports and 10 case series. The median age of patients who developed COVID-19 vaccine-associated ITP was 54 years (IQR 36-72 years). The mRNA-based COVID-19 vaccines, including BNT16B2b2 and mRNA-1273, were most implicated (75.4%). Those were followed by the adenovirus vector-based vaccines, inclusive of ChAdOx1 nCoV-19 and vAd26.COV2.S. No report was found relating ITP to other COVID-19 vaccines. Most cases (79.2%) developed ITP after the first dose of COVID-19 vaccination. 75% of the patients developed ITP within 12 days of vaccination, indicating a shorter lag time compared to ITP after routine childhood vaccinations. Sixty-seven patients (87%) patients were hospitalized. The management pattern was similar to primary ITP, and systemic glucocorticoids, IVIg, or both were the basis of the treatment in most patients. Most patients achieved therapeutic goals; only two individuals required a secondary admission, and one patient who presented with intracranial hemorrhage died of the complication.

CONCLUSIONS

De novo ITP is a rare complication of COVID-19 vaccination, and corresponding reports belong to mRNA-based and adenovirus vector-based vaccines, in order of frequency. This frequency pattern may be related to the scale of administration of individual vaccines and their potency in inducing autoimmunity. The more the COVID-19 vaccine is potent to induce antigenic challenge, the shorter the lag time would be. Most patients had a benign course and responded to typical treatments of primary ITP.

Immune thrombocytopenia in infants: a retrospective study with comparison to toddlers

Introduction

Immune thrombocytopenia (ITP) is the most common cause of acquired bleeding in childhood, but little is known about the clinical course and outcomes in infants with ITP.

Methods

This is a retrospective study of all infants (1-12 months of age) and toddlers (13-47 months of age) diagnosed with ITP from a single centre during a 13-year period. The following data were compared between the two patients groups: demographics, severity of bleeding, platelet counts, duration of illness, development of chronic ITP, treatment and association with recent vaccination.

Results

Twenty-two infants and 30 toddlers were diagnosed and followed up for ITP during the study period. Infants with ITP generally had minor or mild bleeding (19, 86.4%) and seldom required treatment (7, 31.8%), and their thrombocytopenia resolved at a mean of 1.90 months after diagnosis. Besides age, the sex ratio, severity of bleeding, platelet counts and proportion that required treatment were comparable between infants and toddlers. Fewer infants developed chronic ITP (1/22 vs. 9/30, P = 0.032), but more infants had a history of vaccination in the preceding 6 weeks prior to diagnosis of ITP (13/22 vs. 1/30, P < 0.001).

Conclusion

ITP in infants is almost always a self-limiting and transient illness, and the majority of cases do not require treatment.

Acute Thrombotic Thrombocytopenic Purpura: Rare and Life-Threatening Side Effect of Recent BNT-162b2 COVID-19 Vaccination

Description Thrombotic thrombocytopenic purpura (TTP) is a rare, potentially life-threatening disorder characterized by uncontrolled and spontaneous clot formation throughout the body. Known secondary causes of TTP include malignancy, bone marrow transplantation, pregnancy, various medications, and HIV infection. TTP in the setting of COVID-19 vaccination is rare and not well reported. Reported cases have been confined primarily to the AstraZeneca and Johnson and Johnson COVID-19 Vaccines. TTP in the setting of Pfizer BNT-162b2 vaccination has only recently been reported. We present a patient with no obvious risk factors for TTP who presented with acute altered mental status and was found to have objective evidence of TTP. To our knowledge, there are very few reported cases of TTP in the setting of a recent Pfizer COVID-19 vaccination.

Splenectomy in patients with immune (idiopathic) thrombocytopenic purpura (ITP) appears to be protective against developing aortic valve disease

BACKGROUND

Immune thrombocytopenia (ITP) has been shown to be independently associated with aortic valve disease (AVD). However, whether ITP patients who have undergone splenectomy are also at increased risk for AVD has not been researched. The goal of this study was to evaluate any association between AVD and splenectomy in patients with ITP.

METHOD

We used the Nationwide Inpatient Sample from 2005 to 2014 as 10 consecutive years randomly selected. Using ICD-9 codes for AVD, ITP, and splenectomy, a total of 108,434 patients were identified with ITP, 4,282 of which had undergone splenectomy. We performed uni- and multivariate analysis adjusting for baseline characteristics.

RESULTS

Univariate analysis revealed a significantly lower rate of AVD in ITP patients with splenectomy compared to no splenectomy in 2007, 2009, and 2010 with a trend of this association during the other years. For example, in 2007, 0.6% of ITP patients with history of splenectomy had AVD versus 2.0% of ITP patients without splenectomy (OR, 0.29; 95% CI, 0.09-0.91; P = 0.02). Similarly, in 2010, 0.2% of ITP patients with history of splenectomy had AVD versus 1.9% of ITP patients without splenectomy (OR, 0.13; 95% CI, 0.02-0.92; P = 0.02). After adjusting for age, gender, race, diabetes, hypertension, hyperlipidemia, and tobacco use, we confirmed that ITP patients with splenectomy have no association with prevalence of aortic valve disease (2005: OR, 0.48; 95% CI, 0.18-1.30; P = 0.15; 2014: OR, 0.88; 95% CI, 0.36-2.16; P = 0.77).

CONCLUSION

Based on a large inpatient database, our previous finding of ITP patients' association with AVD is only present in patients without splenectomy, and splenectomy appears to exert a protective effect on developing aortic valve disease in ITP patients, warranting further investigation.

A Systematic Review of Reported Cases of Immune Thrombocytopenia after COVID-19 Vaccination

With the recent outbreak of the COVID-19 pandemic and emergency use authorization of anti-SARS-CoV-2 vaccines, reports of post-vaccine immune thrombocytopenia (ITP) have gained attention. With this systematic review, we aim to analyze the clinical characteristics, therapeutic strategies, and outcomes of patients presenting with ITP after receiving COVID-19 vaccination. Medline, Embase, and Ebsco databases were systematically explored from inception until 1 June 2022. Case reports and case series investigating the association between the anti-SARS-CoV-2 vaccine and ITP were included. We found a total of 66 patients. The mean age of presentation was 63 years with a female preponderance (60.6%). Sixteen patients had pre-existing ITP. The mean time from vaccine administration to symptom onset was 8.4 days. More ITP events were triggered by mRNA vaccines (BNT162b2 (n = 29) > mRNA-1273 (n = 13)) than with adenoviral vaccines (ChAdOx1-S AstraZeneca (n = 15) > Ad26.COV2-S (n = 9)). Most of the patients were treated with steroids or IVIG, or both. The overall outcome was promising, with no reported deaths. Our review attempts to increase awareness among physicians while evaluating patients presenting with thrombocytopenia after receiving the vaccine. In our solicited opinion, the rarity of these events and excellent outcomes for patients should not change views regarding the benefits provided by immunization.

NMR-Based Metabolomics Identify Metabolic Change in Spleen of Idiopathic Thrombocytopenic Purpura Patients

Idiopathic thrombocytopenic purpura (ITP) is a common hematological disease and the abnormal platelet destruction in the spleen is a critical pathological mechanism for ITP. However, the metabolomic change in the spleen caused by ITP is still unclear. In the present study, the metabolomic information of 18 ITP and 20 normal spleen samples were detected by using ¹H high-resolution magic angle spinning NMR spectroscopy (¹H MAS NMR). Compared with normal spleen, the concentrations of acetate, alanine, glutamine, glycerol, isoleucine, lysine, valine, phenylalanine, leucine, and methanol in ITP spleen tissue were elevated and 3-hydroxybutyric acid, ascorbate, asparagine, ethanol, glycogen, low-density lipoprotein, malonate, myo-inositol, glycerophosphocholine, pyroglutamate, and taurine were decreased. Amino acids metabolic pathways, such as branched-chain amino acids pathway, were identified as the main involved pathways based on enrichment analysis. The decrease in taurine level in the spleen was the most obvious metabolic signature involving ITP with high sensitivity and specificity to distinguish the spleen of ITP from the normal (CI: 0.825–0.982). Notably, the level of taurine in the spleen was negatively correlated with the efficacy of splenectomy (r = 0.622, p = 0.006). Collectively, the data from our study revealed previously unknown ITP-related metabolomic changes in the spleen and found a potential diagnostic and efficacy-predictive biomarker for ITP treatment.

A very rare case of splenosis and acquired chronic non-cirrhotic portal vein thrombosis with cavernous transformation

We present a clinical case of a young woman who underwent splenectomy for thrombocytopenic splenomegaly at the age of 7 years. An acute diagnostic picture of splenosis of the left epigastric region and chronic non‐cirrhotic portal vein thrombosis with cavernous transformation was found 20 years later.

Fuchs Syndrome with Isolated Oral Mucosa Lesions due to Severe Herpes Simplex Cheilitis in a Patient with Idiopathic Thrombocytopenic Purpura

Stevens-Johnson syndrome (SJS) is a severe dermatological disease classically characterized by erythematous target lesions and mucosal involvement. Fuchs syndrome is an incomplete presentation of SJS which has oral, conjunctival and genital manifestations but no skin lesions. To the best of our knowledge, our case of Fuchs syndrome in an 80-year-old man is the first such case related to herpes simplex virus (HSV)-1 infection to be described. Our patient quickly recovered following IVIG therapy, although specific treatment is still a topic of discussion. Research is required on this poorly understood dermatological disease to determine optimum therapy.

LEARNING POINTS

We report a case of Fuchs syndrome in an elderly man after HSV-1 cheilitis.Therapy always includes discontinuation of the causative drug.Specific therapy for Stevens-Johnson syndrome and Fuchs syndrome is still a topic of discussion, although we noted marked improvement following the administration of IVIG therapy.

Diagnostic value of platelet parameters and megakaryocyte formula of bone marrow in idiopathic thrombocytopenic purpura

The parameters of the megakaryocyte formula and peripheral blood platelet indices were studied in 237 people with diagnoses of idiopathic thrombocytopenic purpura (ITP) and myelodysplastic syndrome (MDS). A correlation analysis was performed between megakaryocyte subpopulations and platelet counts. The threshold values for MPV, PCT and PDW were determined by ROC analysis with the construction of the ROC curve, the calculation of the area under the curve (AUC) and the cutoff threshold. The obtained values make it possible to make a differential diagnosis between ITP and MDS by platelet parameters of peripheral blood without examining the bone marrow.

A Case of Idiopathic Thrombocytopenic Purpura After Booster Dose of BNT162b2 (Pfizer-Biontech) COVID-19 Vaccine

Vaccination is now considered the best measure in minimizing the morbidity and mortality from the Covid-19 pandemic. Almost all the vaccines are considered safe except for minor and occasional side effects. Some of the commonly reported complications from the COVID-19 vaccines are vaccine-induced thrombotic thrombocytopenia (VITT)/thrombosis with thrombocytopenia syndrome/vaccine-induced pro-thrombotic immune thrombocytopenia syndrome.

In this case report, we present a case of a 75-year-old female who had an uncomplicated first and second vaccine dose but developed VITT after the booster dose of the vaccine. The patient was treated with dexamethasone and platelet transfusions. So far no such cases have been reported after the third (booster) dose of the Pfizer-Biontech vaccine.

With this case report, we present the case of the patient and discuss the literature related to vaccine-induced thrombocytopenia.

Impact of target-mediated drug disposition on hetrombopag pharmacokinetics and pharmacodynamics in Chinese healthy subjects and patients with chronic idiopathic thrombocytopenic purpura

AIMS

The pharmacokinetics (PK) of hetrombopag were found to be nonlinear across evaluated dose ranges. The aim of this study was to develop a mechanism-based population pharmacokinetic/pharmacodynamic (PopPK/PD) model and to provide a reasonable expected therapeutic dose for a future confirmatory clinical study of hetrombopag.

METHODS

Nonlinear mixed-effects modelling was performed using pooled 2168 hetrombopag concentrations and 1526 platelet counts from 72 healthy subjects and 32 chronic idiopathic thrombocytopenic purpura (ITP) patients from two phase I studies and one phase II study. The final model was evaluated via goodness-of-fit plots, visual predictive check and nonparametric bootstrap. Simulations from the validated PopPK/PD model were used to devise an expected therapeutic dose for later confirmatory clinical study.

RESULTS

The pharmacokinetic data of hetrombopag were well described by a modified target-mediated drug disposition (TMDD) model with dual sequential first-order absorption. Mean parameter estimates (interindividual variability) were CL/F 7.66 L/h (63.5%), V_c /F 30.0 L (77.2%) and K_deg 0.693/h (87.1%). The pharmacodynamic profile was well described by a five-compartment lifespan model with four-transit and one-platelet compartments. Simulation results suggested that chronic ITP patients following 10 mg once-daily hetrombopag would able to achieve an ideal platelet count level (50-200 × 10⁹ /L).

CONCLUSION

TMDD was the primary reason leading to nonlinear PK profile of hetrombopag. Our PK/PD modelling and simulation results support 10 mg once-daily as the recommended therapeutic dose for chronic ITP patients in subsequent confirmatory clinical study of hetrombopag.

Novel therapies for immune thrombocytopenia

Current therapies for immune thrombocytopenia (ITP) are successful in providing a haemostatic platelet count in over two-thirds of patients. Still, some patients have an inadequate response and there is a need for other therapies. A number of novel therapies for ITP are currently being developed based upon the current pathophysiology of ITP. Many therapies are targetted at reducing platelet destruction by decreasing anti-platelet antibody production by immunosuppression with monoclonal antibodies targetted against CD40, CD38 and the immunoproteasome or physically reducing the anti-platelet antibody concentration by inhibition of the neonatal Fc receptor. Others target the phagocytic system by inhibiting FcγR function with staphylococcal protein A, hypersialylated IgG, polymeric Fc fragments, or Bruton kinase. With a recognition that platelet destruction is also mediated by complement, inhibitors of C1s are also being tested. Inhibition of platelet desialylation may also play a role. Other novel therapies promote platelet production with new oral thrombopoietin receptor agonists or the use of low-level laser light to improve mitochondrial activity and prevent megakaryocyte apoptosis. This review will focus on these novel mechanisms for treating ITP and assess the status of treatments currently under development. Successful new treatments for ITP might also provide a pathway to treat other autoimmune disorders.

Evaluating association between idiopathic thrombocytopenic purpura and hypertension

PURPOSE

The role of platelets in the pathogenesis of hypertension is not well known. The aim of this study was to ascertain if patients with immune thrombocytopenia (ITP) had different rates of hypertension.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample (NIS) database, we analyzed the correlation between hypertension and ITP from the years 2002-2011.

RESULTS

We found no significant differences in the rate of hypertension between ITP and Non-ITP patients. For instance, in 2002, 25.90% of patients with ITP had a concurrent diagnosis of hypertension, compared with 26.53% of Non-ITP patients. Then in 2011, 31.95% of patients with ITP had a concurrent diagnosis of hypertension, compared with 32.31% of Non-ITP patients.

CONCLUSION

Based on our large database, the presence of ITP does not appear to be associated with an increased or decreased risk of hypertension.

The presence of idiopathic thrombocytopenic purpura correlates with lower rate of acute ST-elevation myocardial infarction

Background: Platelets are important in the pathogenesis of myocardial infarction (MI). We hypothesize that patients with acquired thrombocytopenia such as idiopathic thrombocytopenic purpura (ITP) may have lower MI rate. Materials & method: The Nationwide Inpatient Sample was used for this study. We analyzed the correlation between ST-elevation MI (STEMI) and ITP utilizing ICD-9 codes. Results: STEMI rate was lower in patients with ITP. We found that, in 2002, STEMI occurred in 0.64% of patients with ITP versus 0.89 (p < 0.007) and for 2011 0.30 versus 0.48 (p < 0.005). After adjusting for tobacco use, diabetes, hypertension, hyperlipidemia, gender and age, STEMI rate remained lower in ITP patients. Conclusion: ITP appears to be associated with lower STEMI rate suggesting low platelet count may exert protective effect from STEMI.

Different Chinese herbal medicine therapy for idiopathic thrombocytopenic purpura: A protocol for systematic review and Bayesian network meta-analysis

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) is a common immune system and blood system disease in clinical practice, and it is a hemorrhagic disease caused by immune factors causing platelet destruction and decreasing number of platelets. There is currently no effective treatment plan for ITP. At this stage, glucocorticoid and gamma globulin are mostly used in the treatment of ITP, and some patients use splenectomy to achieve therapeutic purposes, but the various treatment methods are inadequate. At this stage, a large number of randomized controlled studies have reported that Chinese herbal medicine has achieved good curative effect in the treatment of ITP. However, due to the variety of Chinese herbal medicine, there has been no evidence of the effectiveness and safety of Chinese herbal medicine in the treatment of ITP. Because of the above reasons, this study uses the network meta-analysis method based on Bayesian method to compare the clinical efficacy and safety of different kinds of Chinese herbal medicine in the treatment of ITP through direct and indirect comparison, in order to provide evidence-based medical support for the treatment of ITP with Chinese herbal medicine.

METHODS

This study uses the method of combining free words with theme words, and using computer to retrieve PubMed, EMbase, The Cochrane Library, WANFANG Database, CNKI, and VIP Database, etc, to collect the randomized control studies on Chinese herbal medicine in the treatment of ITP. The retrieval time is from the establishment of each database to January 2021, and the retrieval languages are Chinese and English. Two researchers independently read the title, abstract and full text of the article to determine whether it is included in the literature; In the event of a disagreement, a third researcher will join the discussion to resolve the disagreement; For the literature that lacks information, trying to contact the original author of the document to supplement it. The literature quality evaluation carried out by using the Stata 14.0 software to draw network and funnel plots, in accordance with the quality evaluation criteria of version 5.1.0 of the Cochrane System Evaluation Manual. Statistical analysis is performed by using ADDIS 1.16.8 software based on the Bayesian model.

RESULTS

This study will compare the clinical efficacy and safety of different types of Chinese herbal medicine in the treatment of idiopathic thrombocytopenic purpura through the method of network meta-analysis, and rank the different types of Chinese herbal medicine according to their effectiveness, and the results will be published in a peer-reviewed, high-quality academic journal.

CONCLUSION

This study will find effective and safe Chinese herbal medicine for clinical treatment of ITP from the perspective of evidence-based medicine, and benefit more ITP patients.

Renal cell carcinoma associated with idiopathic thrombocytopenic purpura

We presented the clinical data of one patient with renal cell carcinoma associated with idiopathic thrombocytopenic purpura in this case report. We reported a 56-year-old man who presented with petechiae and ecchymoses. Laboratory studies showed the platelet count of 2 × 10⁹/L and an abdominal computed tomography (CT) scan revealed tumors in the right renal. There were purpura on the legs and cough without abdominal pain and melena at this time. Idiopathic thrombocytopenic purpura was diagnosed according to the clinical symptoms and laboratory test. The patient received radical nephrectomy for renal carcinoma, and his idiopathic thrombocytopenic purpura was cured after the surgery. Pathological biopsy confirmed it was renal clear cell carcinoma. The patient has been followed up for more than 3 months after surgery, and the ecchymoses had not been recurred and the patient’s thrombocytopenia was recovered. Idiopathic thrombocytopenic purpura associated with kidney cancer is rare. The patient in this case report was treated with radical nephrectomy, and the effectiveness of idiopathic thrombocytopenic purpura was satisfactory.

The Need for Comprehensive Care for Persons with Chronic Immune Thrombocytopenic Purpura

Chronic platelet disorders (CPD), including chronic immune thrombocytopenic purpura (cITP), thrombotic thrombocytopenic purpura (TTP) and platelet function disorders are among the most common bleeding disorders and are associated with morbidity and mortality. The clinical phenotype and complexity of cITP is much like that of hemophilia. In cITP and hemophilia, bleeding is problematic for many, complicating employability, insurability and overall quality-of-life (QoL). While myriad drug therapies are available for cITP and hemophilia, each are variable in their effectiveness, very few (except for clotting factor concentrates for hemophilia) alter the natural history of the disorder and sometimes contribute to specific morbidities and mortality. Like in hemophilia, the management of cITP is not solely based on access to effective treatment but also includes accurate diagnosis and comprehensive care by a multidisciplinary team of specialists trained in the management of bleeding disorders. The model of comprehensive care in Hemophilia Treatment Centers (HTCs) has been recognized as highly effective, improving life expectancy for persons with hemophilia. cITP, and other CPDs, are complex disorders requiring specialized care. However, an integrated care model with a systematic and reliable population-based surveillance program does not exist. Extending the Comprehensive Care model with all its related benefits to the community of persons with cITP is sorely needed. This review will focus on cITP as a prototype chronic platelet disorder that could benefit greatly from the Comprehensive Care model.

A simple HPLC assay for determining eltrombopag concentration in human serum

Eltrombopag, a thrombopoietin receptor agonist, is used for the treatment of idiopathic thrombocytopenic purpura (ITP) and aplastic anemia. We developed a HPLC assay for the determination of serum eltrombopag concentration in ITP patients. An aliquot of a serum sample spiked with diclofenac as the internal standard (IS) was treated with acetonitrile to precipitate the proteins. Eltrombopag and the IS were separated on an octadecylsilyl silica-gel column using a mobile phase consisting of 10 mM 1-pentanesulfonic acid sodium salt, acetonitrile, and acetic acid. The detection wavelength was set at 265 nm. The calibration curve was linear at the concentration range of 0.15-12.5 μg/mL for eltrombopag (r = 0.9987). The recoveries of eltrombopag from the serum samples were greater than 95.9% with coefficients of variation (CVs) being less than 2.8%. The CVs for the intra-day and inter-day assays were 1.9-11.8% and 1.0-11.8%, respectively. This assay method could be used for therapeutic drug monitoring of eltrombopag in ITP patients.

Severe thrombocytopenia in patients with idiopathic pulmonary arterial hypertension provided several strategies for lung transplantation

While the prognosis of idiopathic pulmonary arterial hypertension has improved significantly due to newer medications, lung transplantation remains a critical therapeutic option for severe pulmonary arterial hypertension. Hence, it is essential for patients awaiting lung transplantation to avoid complications, including thrombocytopenia, which may affect their surgical outcomes. Herein we present the case of a 21-year-old woman diagnosed with idiopathic pulmonary arterial hypertension at the age of 15. She developed thrombocytopenia while awaiting lung transplantation. Her medication was switched from epoprostenol to treprostinil, suspecting possible drug-induced thrombocytopenia. Furthermore, she was administered thrombopoietin receptor agonists in view of the possibility of idiopathic thrombocytopenic purpura, along with maximum support for right heart failure. Subsequently, her platelet count increased to >70,000/µL, enabling her to successfully undergo bilateral lung transplantation. Post-bilateral lung transplantation, pulmonary arterial hypertension as well as thrombocytopenia appeared to have resolved. In this case, we suspected that thrombocytopenia could have resulted owing to a combination of pulmonary arterial hypertension, right heart failure, drug interactions, and idiopathic thrombocytopenic purpura. Thrombocytopenia is a very critical condition in patients with pulmonary arterial hypertension, especially those awaiting lung transplantation. Several approaches are known to improve intractable thrombocytopenia in patients with pulmonary arterial hypertension.

Clinical Characteristics and Outcomes of Pediatric Patients With Immune Thrombocytopenic Purpura in King Abdulaziz Medical City and King Abdullah Specialist Children's Hospital: A 10-Year Study

Background

Immune thrombocytopenic purpura (ITP) can be defined as “an immune-mediated acquired disease characterized by a transient or persistent decrease in the platelet count”. Medical treatment is usually not needed but, in some cases, intravenous immunoglobulin G (IVIG), corticosteroids, and anti-D immunoglobulins are used. Splenectomy can be an option for chronic cases with no response to pharmacological treatments. The aim of this study was to describe the clinical characteristics and outcomes of pediatric patients with ITP in King Abdulaziz Medical City (KAMC) and King Abdullah Specialist Children’s Hospital (KASCH) in a 10-year period.

Methods

The study was conducted at KAMC and KASCH. The number of recorded cases was 95, which included all ITP patients aged 1 to 14 from both genders who presented to KAMC previously and KASCH currently from January 1, 2007, to December 31, 2017. The data analysis and entry were performed using the Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY).

Results

Among 95 pediatric patients with ITP, 51 (53.7%) were males and 44 (46.3%) were females, with a median age of 4.00 ± 3.977. Among them, 84 (92.7%) had purpura, 38 (46.3%) had epistaxis, 43 (39%) had petechia, 17 (24.3%) had fever, and 20 (19.5%) had gum bleeding. Out of 95 patients, 91 (95.8%) were given treatment. Out of those 91 patients who were given treatment, IVIG was used in 84 (92.3%), steroids were used in 44 (48.4%), 14 patients received platelet transfusion (15.4%), rituximab was used in 7 (7.7%), and splenectomy was done in 5 (5.5%); 32 (33.7%) cases were considered chronic (more than one year), and 63 (66.3%) were considered acute. Among chronic patients, only one death was recorded, while in acute, no deaths were recorded.

Conclusion

In conclusion, ITP is an autoimmune disease that decreases platelet count. The results showed a significant difference in treatment compared to the literature but similar results in other aspects.

Romiplostim treatment for children with immune thrombocytopenia: Results of an integrated database of five clinical trials

BACKGROUND

Treatment for chronic immune thrombocytopenia (cITP) in children is largely limited to immunosuppressive agents. Thrombopoietin receptor agonists (TRAs) have been used to treat cITP in adults for over a decade. The objective of this integrated analysis was to examine the safety and efficacy of the TRA romiplostim in children with ITP.

METHODS

We examined efficacy and safety in children with ITP across five romiplostim trials: final data from two double-blind placebo-controlled trials and two open-label extensions, and interim data from an ongoing single-arm trial.

RESULTS

Patients (n = 24 initially placebo; n = 262 initially romiplostim) had a median age of 10.0 years (Q1: 6.0, Q3: 13.0), ITP duration of 1.9 years (Q1: 1.0, Q3: 4.0), and baseline platelet count of 14.3 × 10⁹ /L (Q1: 7.5, Q3: 23.0). Among 282 patients receiving romiplostim, median treatment duration was 65 weeks (range 8-471 weeks) and median weekly dose was 6.6 μg/kg (range 0.1-9.7 μg/kg). Overall, 89% of romiplostim-treated patients had platelet responses. Nineteen patients (7%) maintained treatment-free responses for ≥6 months while withholding all ITP therapy. Grade 3 and 4 adverse events of bleeding occurred in 10% and <1% of romiplostim-treated patients, respectively. Twenty-five percent of patients had a serious adverse event, most commonly epistaxis (6%). Seven patients (2%) had neutralizing antibodies against romiplostim postbaseline and none had neutralizing antibodies against endogenous thrombopoietin. Efficacy and safety results appeared similar between children with ITP for ≤12 months and >12 months at baseline.

CONCLUSIONS

Across five pediatric clinical trials, romiplostim was well tolerated. Most patients had a platelet response; some maintained responses for at least 6 months while withholding all ITP therapy.

First-in-patient study of hetrombopag in patients with chronic idiopathic thrombocytopenic purpura

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) especially refractory and (or) relapsed ITP, is a serious and global health burden and its clinical treatment is far from being satisfied. Hetrombopag is a novel, small-molecule thrombopoietin receptor agonist for the treatment of chronic idiopathic thrombocytopenic purpura (CITP).

OBJECTIVES

This first-in-patient study aimed to investigate the safety, pharmacokinetics, and anticipated therapeutic dose of hetrombopag in CITP patients.

METHODS

In this multicenter, first-in-patient study, CITP patients received hetrombopag in a dose escalation (2.5 mg/day, 5 mg/day, or 7.5 mg/day) cohort. All patients received hetrombopag in fasting condition once daily for 2 weeks.

RESULTS

Of 44 patients screened, 32 were enrolled and treated. Most adverse events were graded 1 to 2 (ie, mild to moderate), and the incidence and severity were similar for three study cohorts. The pharmacokinetics of hetrombopag were found to be nonlinear with greater than dose-proportional: 12.5% of patients (1/8) in the 2.5 mg/d cohort, 58.3% of patients (7/12) in the 5 mg/d cohort, 66.7% of patients (8/12) in the 7.5 mg/d cohort reached the primary study endpoint of a platelet count exceeding 50 × 109 /L on day 28.

CONCLUSION

Hetrombopag was well tolerated and preliminarily efficacious. Efficacy, safety, and pharmacokinetic data suggest that 7.5 mg hetrombopag once daily was the anticipated therapeutic dose of hetrombopag in CITP patients and has been recommended for investigation in a later confirmatory clinical study of hetrombopag.

Fostamatinib is an effective second-line therapy in patients with immune thrombocytopenia

Fostamatinib demonstrated efficacy in phase 3 trials of adults with immune thrombocytopenia (ITP). Post hoc analysis compared patients who received fostamatinib as second‐line therapy (after steroids ± immunoglobulins) versus third‐or‐later‐line therapy (after ≥2 prior lines of therapy including a second‐line agent). Platelet responses ≥50 000/µl were observed in 25/32 (78%) second‐line and 54/113 (48%) third‐or‐later‐line patients. Bleeding events were less frequent in second‐line (28%) versus third‐or‐later‐line (45%) patients. Responses once achieved tended to be durable in both groups. The safety profile was similar in both groups. In this post hoc analysis, fostamatinib was more effective as second‐line than third‐or‐later‐line therapy for ITP.

Long-term Successful Treatment of Rituximab for Steroid-resistant Minimal Change Nephrotic Syndrome and Idiopathic Thrombocytopenic Purpura

A 22-year-old woman had been diagnosed with idiopathic thrombocytopenic purpura (ITP) 5 years earlier. After undergoing splenectomy, she relapsed frequently following prednisolone tapering. She was complicated with minimal change nephrotic syndrome (MCNS) while taking 20 mg of prednisolone. Despite treatment with prednisolone, cyclosporin and low-density lipoprotein-apheresis, MCNS and ITP did not improve. We added rituximab in 4 weekly infusions of 375 mg/m². MCNS and ITP were in complete remission. After administering rituximab once, all medicines were discontinued. No relapse had occurred by 50 months following the first rituximab administration. Rituximab affects steroid-resistant MCNS and ITP for a long time without complications.

Femoral pseudotumor secondary to injury in a patient with idiopathic thrombocytopenic purpura: Case report

RATIONALE

Idiopathic thrombocytopenic purpura (ITP) is the condition of having a low platelet count of unknown causes and is a poorly understood acquired hemorrhagic disease involving destruction of platelets in the reticuloendothelial system induced by antiplatelet antibodies. Patients with ITP can have traumatic intra-articular, intraosseous or soft tissue hemorrhage which may present as a rare intraosseous pseudotumor on medical imaging.

PATIENT CONCERNS

A 30-year old male patient had complaint of pain in the right leg for 1 year. Laboratory test revealed a much lower platelet count (3-12 × 10/L).

DIAGNOSES

Radiography and computed tomography showed expansive bone destruction in the distal segment of the right femur, and magnetic resonance imaging revealed heterogeneous signal intensity in the lesion. Lesion curettage and pathology showed an expansion cyst with a really thin cortical bone shell containing serum-like red liquid and some sediment-like deposit. Consequently, the diagnosis of a pseudotumor was confirmed.

INTERVENTIONS

Lesion curettage and bone graft surgery were performed, and 8 units of platelet were transfused to the patient. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination.

OUTCOMES

The platelet count was 308 × 10/L 5 days after operation, and the clotting time was normal. At 6 month follow-up after lesion curettage, the patient remained normal with no deterioration in the lesion site.

CONCLUSION

The diagnosis of a pseudotumor of ITP relies mainly on imaging findings of the lesion and, in particular, knowledge of the underlying bleeding disorders. Radiologist and pathologist should be aware of the characteristics of this rare complication of ITP and other bleeding disorders like hemophilia in order to avoid misinterpretation of the lesion as a tumor or infection disease.

5 Years' Experience of a Tertiary Center with Thrombocytopenic Pregnancies: Gestational Thrombocytopenia, Idiopathic Thrombocytopenic Purpura and Hypertensive Disorders of Pregnancy

Aim To evaluate thrombocytopenic pregnancies including gestational thrombocytopenia (GT), idiopathic thrombocytopenic purpura (ITP), and hypertensive disorders of pregnancy (HDP).

Materials and Methods We evaluated the pregnancy outcomes and laboratory findings of 385 patients diagnosed with GT, ITP, or HDP whose thrombocyte levels were < 150 000/µL.

Results GT, ITP, and HDP were the final diagnoses in 315 (81.8%), 35 (9.1%), and 35 (9.1%) cases, respectively. Patients diagnosed during the 1st trimester and diagnosed with ITP had significantly lower minimal platelet counts during the antenatal period and prior to delivery (p < 0.001; p < 0.001; p < 0.001; p < 0.001). Transfusion of any kind of blood product was given in 9.9% (n = 38) of all cases. Twelve patients had methylprednisolone and/or intravenous immunoglobulin treatments during the antenatal period. All patients who had undergone medical treatment were also found to have ITP. Four out of 385 patients underwent hysterectomy post partum due to refractory hemorrhage. Analysis of newborn platelet levels showed no statistical differences between any of the groups. Despite the lack of statistical significance, the rate of thrombocytopenia in newborns was 50% in patients with severe thrombocytopenia, while rates were 25.6 and 18.1% in patients with moderate and mild thrombocytopenia, respectively.

Conclusion Thrombocytopenic pregnancies must be carefully evaluated with regard to the severity of thrombocytopenia, gestational period at initial diagnosis, and etiology. In particular, patients with ITP must be evaluated carefully as these patients are more likely to require transfusions and have platelet counts < 50 × 10 ³ /µl.

[Exploration on connotation of Zhigancao Decoction formula syndrome from the perspective of modern pathophysiology and severe cases of critical care and its clinical efficacy on cardioversion,maintenance of sinus rhythm,hemostasis,increasing platelets count,and tonifying deficiency]

Zhigancao decoction recorded in Treatise on Febrile Disease by Zhang Zhongjing in the Han dynasty have been widely used in treating palpitation and irregular pulse by traditional Chinese medicine physicians for thousands of years. It is all known that Zhigancao Decoction is used to treat consumptive disease. However,why it has been used to treat exogenous febrile disease? According to studies,Fumai Decoctions in Treatise on Differentiation and Treatment of Epidemic Febrile Disease,that was modified based on Zhigancao Decoction,have their names without reality. Serious defects,including unclear diagnosis,curative effect,and prognosis,have been found in ancient and modern medical records about Zhigancao Decoction. The indications of Zhigancao Decoction include atrial premature beats,ventricular premature beats,and viral myocarditis; tachyarrhythmia( supraventricular tachycardia,atrial fibrillation)with long interval or conduction block,during or after severe infection or high fever; chronic consumptive disease due to tumor after radiotherapy and chemotherapy,malignant fluid state of tumor,hematopathy,terminal stage of heart failure after major operation,and acute hemorrhage after control of severe infection and other major diseases; cough,phlegm and asthma due to chronic obstructive pulmonary disease,pulmonary interstitial fibrosis,lung cancer,after lung cancer surgery; increased heart rate and decreased blood pressure due to insufficient capacity after acute blood loss; the symptoms included palpitation,chest tightness,sweating,lassitude,lacking in strength,shortness of breath,syncope,sudden death,cough,expectoration,excessive phlegm,clear and dilute sputum,emaciation,dry and haggard skin,constipation,haemorrhagic,uterine bleeding,enjoy sweet taste,red tongue without moss,knotted pulse,intermittent pulse,thready rapid pulse,and weak pulse. Besides,Zhigancao Decoction has effect on cardioversion and maintenance of sinus rhythm without thrombosis in persistent atrial fibrillation and permanent atrial fibrillation. Zhigancao Decoction could stop bleeding soon for acute upper gastrointestinal bleeding,and achieve positivity of occult blood test; Zhigancao Decoction could promote thrombocytopenia for idiopathic thrombocytopenic purpura,with the number of platelets 1×109/L. Zhigancao Decoction could promote the rise of granulocytic,erythroid and megakaryocytic hematopoietic lines in unexplained severe anemia,thrombocytopenia,and leukocyte reduction. Zhigancao Decoction could treat cough,asthma,and chest tightness in lung cancer and after lung cancer surgery; chronic consumptive disease due to lung cancer after lung cancer surgery,hematopathy and acute blood loss,which all belonged to the scope of consumptive disease. Zhigancao Decoction could ascend platelets,which was considered as " oriental interleukins" for the ancients. Zhigancao Decoction possesses dual-directional regulation on anticoagulant and hemostasis,which was considered as " oriental low molecular heparin" and " oriental proton pump inhibitors". Large dose of Rehmannia glutinosa is the key of the efficacy of Zhigancao Decoction. This study is expected to enrich the guidelines for modern medical diagnosis and treatment. However,the clinical evidence,relevant genes and targeting network need to be deepened in future studies. In conclusion,it may be a shortcut to restore and explain Zhigancao Decoction formula syndromes based on modern pathophysiology and severe cases of critical care.

When WAS Gene Diagnosis Is Needed: Seeking Clues Through Comparison Between Patients With Wiskott-Aldrich Syndrome and Idiopathic Thrombocytopenic Purpura

Background: Wiskott-Aldrich syndrome (WAS) is a rare and severe X-linked disorder with variable clinical phenotypes correlating with the type of mutations in the WAS gene. The syndrome is difficult to differentiate from idiopathic thrombocytopenic purpura (ITP) before genetic diagnosis. We retrospectively reviewed patients suspected to have WAS who were referred to our hospital from 2004 to 2016 and compared the clinical features and laboratory examination of genetically confirmed WAS patients and of patients diagnosed with ITP in order to seek some clues to distinguish WAS and ITP before genetic diagnosis.

Methods: Seventy-eight children suspected to have WAS from 78 unrelated families were enrolled in this study. The clinical data and laboratory examination of children were reviewed in the present study. The distribution of lymphocyte subsets from peripheral blood was examined by how cytometry. WASP mutations were identified by direct sequencing of PCR-amplified genomic DNA.

Results: Forty-two patients were finally diagnosed with WAS genetically. The median onset age of these patients was 1 month (range: 1 day−10 months). The median diagnosis lag was 4.6 months (range: 0 months−9.42 years). Fifteen patients (35.71%) had positive family histories. More than half of the patients (n = 23, 54.76%) had diarrhea. Twenty-three (54.76%) had pneumonia, 7 with severe symptoms. Major bleeding events included skin spots or petechiae (n = 27, 64.29%), per-rectal bleeding (n = 21, 50.00%), epistaxis (n = 7, 16.67%) and intracranial bleeding (n = 2, 4.76%). Twenty-nine patients (69.05%) had eczema, and one patient had a drug allergy. Three patients had autoimmune diseases, among whom 2 had autoimmune hemolytic anemia and one had autoimmune hemolytic anemia and IgA nephropathy. A total of 42 mutations in WASP were identified, including 19 novel mutations. Eight patients received hematopoietic stem cell transplantation (HSCT) and all survived. Compared with the 30 patients diagnosed with ITP, the WAS patients had higher EOS counts and elevated IgE level, increased NK cell numbers but fewer CD8⁺T lymphocytes.

Conclusion: The WAS gene diagnosis should be considered in all males with ITP-like features, especially for patients with a very early onset age, decreased MPV (<6.5 fl), higher EOS counts and elevated IgE level, increased NK cell number, diminished CD8⁺T lymphocyte count.

Indications and Outcomes of Splenectomy for Hematological Disorders

Background and Aim

Splenectomy is a frequent component of the diagnosis and treatment of hematological disorders. The aim of this study was to define the indications and outcomes of splenectomy for benign and malign hematological disorders.

Materials and Methods

One hundred and two patients with hematological disease who had splenectomy at Hacettepe University Hospital between the years of 2010 and 2018 were evaluated.

Results

A total of one hundred and two patients were included in this study. The median age was 52 (20-82) years at the time of splenectomy. Most of the patients were female (57.9%). The median follow up time was 11.0 (0.03-87.9) months after splenectomy. Splenectomy was performed to diagnose thirty patients (29.4%). Seventy-two patients underwent splenectomy for the treatment of hematological disease (70.6%). Twenty-seven patients (90%) were diagnosed with various lymphomas. Two patients (6.7%) were diagnosed with hairy cell leukemia and one patient (3.3%) was diagnosed with large granular lymphocytic leukemia.

Conclusion

In conclusion, an improvement in medical therapy, especially with monoclonal antibodies, the indications and outcomes of splenectomy for hematologic disorders have changed extremely in last years. Nevertheless, splenectomy has an important role for diagnosis and treatment of benign and malign hematological disorders.

Primary immune thrombocytopenia (ITP) treated with romiplostim in routine clinical practice: retrospective study from the United Kingdom ITP Registry

BACKGROUND

Romiplostim is a thrombopoietin-mimetic peptibody for adult refractory chronic immune thrombocytopenia (ITP). We aimed to describe ITP patients receiving romiplostim, platelet counts and romiplostim usage in UK clinical practice.

METHODS

This was a retrospective cohort study of patients in the UKITP Registry who received romiplostim between October 2009 and January 2015, including data up to 6 months before romiplostim initiation through follow-up.

RESULTS

Of 1440 patients in the UKITP Registry, 118 adults with primary ITP were eligible. Before romiplostim, 22% had splenectomy, 12% received platelet transfusion, 97% received ≥ 1 different ITP medication and 77% received ≥ 3. Most patients (73%) initiated romiplostim ≥ 1 year after ITP diagnosis (chronic phase). The mean duration of romiplostim treatment was 5.7 (SE 0.9) months, and the median was 1.4 months (IQR: 0.2, 6.5). Mean platelet count before romiplostim was 38 × 10⁹ /L, rising to 103 × 10⁹ /L within 1 month, and remaining 50-150 × 10⁹ /L through up to 3 years of follow-up. After romiplostim, 4% of patients had splenectomy, 6% received platelet transfusion, and 57% received just one ITP medication other than romiplostim.

CONCLUSION

The study provides valuable insights into the real-world use of romiplostim in primary ITP in routine practice and highlighted the timing of romiplostim initiation at different ITP disease phases.

Malignant benign hematology

When faced with a life‐threatening non‐cancerous blood disorder, the term “benign” is a misnomer. Devastating diseases like catastrophic antiphospholipid antibody syndrome, acquired hemophilia, and severe immune thrombocytopenia present a challenge to the hematologist. They are often difficult to treat and lack appropriately powered, unbiased evidence to support management. Moreover, the label “benign” does a disservice as it subconsciously triggers discrepancies in prioritization for the care provider, the system, the patient and his/her family. Despite our progressive advances in non‐malignant hematology, there remain many knowledge and care gaps that can be effectively addressed by more international collaboration, more clinical and research infrastructure and more expertly trained clinicians. To highlight the need, is it time to reconsider the term “benign” hematology?

High-dose Dexamethasone Therapy as the Initial Treatment for Idiopathic Thrombocytopenic Purpura: Protocol for a Multicenter, Open-label, Single Arm Trial

Standard therapy for idiopathic thrombocytopenic purpura (ITP) has not been established. We are conducting a multicenter, prospective trial to determine the efficacy and safety of short-term, high-dose dexamethasone therapy in ITP patients aged 18-80 years with platelet counts of <20, 000 /μL, or with <50, 000/ μL and bleeding symptoms. The primary endpoints of this trial are the proportion of responses (complete plus partial response) on day 180 (day 46+180) after the completion of the 46-day high-dose dexamethasone therapy. The results of this investigation of the effectiveness and safety of this regimen will be essential for the establishment of standard therapy for ITP.

Risk factors for bleeding, including platelet count threshold, in newly diagnosed immune thrombocytopenia adults

Essentials Risk factors of bleeding in adult immune thrombocytopenia are not known. This multicenter study assessed risk factors of bleeding at immune thrombocytopenia onset. Platelet count thresholds associated with bleeding were < 20 × 109 L-1 and < 10 × 109 L-1 . Exposure to anticoagulants was a major risk factor of severe bleeding.

SUMMARY

Background The aim of this cross-sectional study was to assess risk factors for bleeding in immune thrombocytopenia (ITP) adults, including the determination of platelet count thresholds. Methods We selected all newly diagnosed ITP adults included in the Cytopénies Auto-immunes Registre Midi-PyrénéEN (CARMEN) register and at the French referral center for autoimmune cytopenias. The frequencies of any bleeding, mucosal bleeding and severe bleeding (gastrointestinal, intracranial, or macroscopic hematuria) at ITP onset were assessed. Platelet count thresholds were assessed by the use of receiver operating characteristic curves. All potential risk factors were included in logistic regression models. Results Among the 302 patients, the frequencies of any, mucosal and severe bleeding were 57.9%, 30.1%, and 6.6%, respectively. The best discriminant threshold of platelet count for any bleeding was 20 × 109 L-1 . In multivariate analysis, factors associated with any bleeding were platelet count (< 10 × 109 L-1 versus ≥ 20 × 109 L-1 , odds ratio [OR] 48.2, 95% confidence interval [CI] 20.0-116.3; between 10 × 109 L-1 and 19 × 109 L-1 versus ≥ 20 × 109 L-1 , OR 5.2, 95% CI 2.3-11.6), female sex (OR 2.6, 95% CI 1.3-5.0), and exposure to non-steroidal anti-inflammatory drugs (NSAIDs) (OR 4.8, 95% CI 1.1-20.7). A low platelet count was also the main risk factor for mucosal bleeding. Exposure to anticoagulant drugs was associated with severe bleeding (OR 4.3, 95% CI 1.3-14.1). Conclusions Platelet counts of < 20 × 109 L-1 and < 10 × 109 L-1 were thresholds for major increased risks of any and mucosal bleeding. Platelet count, female sex and exposure to NSAIDs should be considered for assessment of the risk of any bleeding. Exposure to anticoagulant drugs was a major risk factor for severe bleeding.

Helicobacter pylori and extragastric diseases

Many studies have been performed in the last year concerning the potential role of Helicobacter pylori in different extragastric diseases, reinforcing the idea that specific microorganisms may cause diseases even far from the primary site of infection. While the role of H. pylori on idiopathic thrombocytopenic purpura, sideropenic anemia, and vitamin B12 deficiency has been well established, there is a growing interest in other conditions, such as cardiovascular, neurologic, dermatologic, obstetric, immunologic, and metabolic diseases. Concerning neurologic diseases, there is a great interest in cognitive impairment and neurodegeneration. The aim of this review was to summarize the results of the most relevant studies published over the last year on this fascinating topic.

Isolated thrombocytopenia in childhood: what if it is not immune thrombocytopenia?

INTRODUCTION

Childhood immune thrombocytopenia (ITP) remains a diagnosis of exclusion when isolated thrombocytopenia is not part of another disease process. In practice, the diagnosis of ITP can only be confirmed when thrombocytopenia resolves or is excluded after the recognition of a primary cause.

METHODS

The records of 87 consecutive children with isolated thrombocytopenia seen over a nine-year period in a private paediatric haematology practice were reviewed retrospectively. Children in whom a primary cause was eventually found were the subjects of a further descriptive study.

RESULTS

9 (10%) children with isolated thrombocytopenia were not diagnosed with ITP because a primary disease was found. Of these nine cases, four had thrombocytopenia recognised during the neonatal period, consisting of perinatal cytomegalovirus infection (n = 2), meconium aspiration pneumonia (n = 1) and transient abnormal myelopoiesis associated with Down syndrome (n = 1). The remaining five children were each found to have familial thrombocytopenia, portal hypertension, cutaneous mastocytosis, May-Hegglin anomaly and systemic lupus erythematosus. Two of them had a history of failure of response to corticosteroid therapy.

CONCLUSION

Secondary thrombocytopenia is not uncommon in a tertiary paediatric specialty practice with adequate evaluation. Thrombocytopenia occurring during the newborn period and failure of steroid therapy are predictive of secondary cases.

Concurrent Autoimmune Neutropenia and Idiopathic Thrombocytopenic Purpura Associated with IgG4-related Diease

IgG4-related disease (IgG4RD) is a multi-organ disorder characterized by an elevated serum IgG4 level and IgG4-positive plasma cell infiltration of the affected organs, accompanied by tissue fibrosis and sclerosis. Although it can affect any organ, to our knowledge, no cases involving concurrent autoimmune neutropenia and thrombocytopenia have been reported. A 62-year-old man visited our hospital and was diagnosed with IgG4RD accompanied by interstitial pneumonitis, lymphadenopathy, and interstitial nephritis. During his clinical course, he developed autoimmune neutropenia and idiopathic thrombocytopenic purpura. Our case, invoving multiple hematological abnormalities, might help deepen our understanding of the pathophysiology of IgG4RD.

The Role of Hydroxychloroquine as a Steroid-sparing Agent in the Treatment of Immune Thrombocytopenia: A Review of the Literature

Immune Thrombocytopenia (ITP) is an autoimmune disease in which platelet destruction causes thrombocytopenia. Due to the known steroid toxicities, alternative agents have been evaluated for the treatment of these patients. We aimed to review the literature and find evidences regarding the potential benefits of hydroxychloroquine (HCQ) as a steroid-sparing agent in the treatment of ITP. We searched English language articles within Web of Science, PubMed, and Scopus. Cohorts, clinical trials, case reports, conference papers, and letters were included. We excluded papers which either focused on administration of HCQ for non-ITP conditions or studies on other treatment modalities for ITP. In total, 54 ITP cases with either primary or systemic lupus erythematosus (SLE)-associated ITP were included in four studies (SLE-associated ITP; n = 23). All patients have received corticosteroids previously and >90% received other agents with HCQ concomitantly. Overall response was achieved in more than 60% of patients. Sustained response in 18 (33.3%) patients was associated with no treatment or HCQ alone. One of the studies reported a significantly better response in patients with definite SLE compared to those with positive antinuclear antibody and no definite SLE. Similarly, another study found a nonsignificant trend toward better long-term response in patients with definite SLE compared to incomplete SLE. The included articles reported the efficacy of the HCQ with acceptable safety. Available data regarding the use of HCQ for this indication are spare and more studies are needed in ITP with different severity. It seems that HCQ can be considered as an option in the treatment of SLE-associated ITP, and although promising, currently, the place of HCQ in the treatment of ITP continues to evolve.

Isolated Shoulder Palsy due to Intracerebral Hemorrhage

A small cortical infarction confined to the medial location of the precentral knob on the precentral gyrus may cause isolated shoulder palsy. However, there are no reports indicating intracerebral hemorrhage as a cause of isolated shoulder palsy. We herein report the case of a 48-year-old man who presented with isolated shoulder palsy as an initial symptom of subcortical hemorrhage at the precentral gyrus. Such cases may be easily misdiagnosed as shoulder or cervical spine problems. The distribution of muscle weakness is the key to an accurate diagnosis.

Neurosurgical management in children with bleeding diathesis: auditing neurological outcome

OBJECTIVE The aim of this study was to assess the outcome of neurosurgical treatment in children with bleeding diathesis and also to evaluate the current management plan applied in the authors' service. METHODS The authors retrospectively analyzed all cases in which neurosurgical procedures were performed in pediatric patients presenting with intracranial hematoma due to an underlying bleeding tendency over a 5-year period at their institution. They evaluated the patients' neurological symptoms from the initial referral, hematological abnormalities, surgical treatment, neurological outcome, and scores on the Pediatric Glasgow Outcome Scale-Extended (GOS-E Peds) obtained 1 year after the last operation. RESULTS Five patients with a bleeding diathesis who underwent surgery for intracranial hematoma were identified; the diagnosis was hemophilia A in 3 cases, idiopathic thrombocytopenic purpura in 1 case, and severe aplastic anemia in 1 case. Intracerebral hematoma (ICH) (n = 4) and acute subdural hematoma (n = 1) were confirmed on radiological investigations. In 2 of the 4 patients with ICH, the diagnosis of bleeding diathesis was made for the first time on presentation. Four patients (all male) were younger than 2 years; the patient with severe aplastic anemia and spontaneous ICH was 15 years old and female. The duration of symptoms varied from 24 hours to 5 days. Neurological examination at 1 year's follow-up showed complete recovery (GOS-E Peds score of 1) in 3 cases and mild weakness (GOS-E Peds score of 2) in 2 cases. CONCLUSIONS Neurosurgical management of patients with bleeding diathesis should be carried out in a tertiary-care setting with multidisciplinary team management, including members with expertise in neuroimaging and hematology, in addition to neurosurgery. Early diagnosis and prompt treatment of a bleeding diathesis is crucial for full neurological recovery.

Acute Kidney Injury, Immune Thrombocytopenic Purpura, and the Infection That Binds Them Together: Disseminated Histoplasmosis

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.

Bias and estimation under misspecification of the risk period in self-controlled case series studies

The self-controlled case series (SCCS) method is useful for estimating the relative incidence (RI) of acute events, such as adverse events (AEs) during a specified risk period following an exposure (e.g., 6-week period after vaccinations or 30-day period after infection-related hospitalizations). In practice, the "optimal" risk period is unknown and must be specified. To date, two approaches are available to guide the specification of the risk period. Both methods do not fully utilize the nature of the bias due to misspecification, which to date has not been characterized. Thus, we elucidate the bias of SCCS estimate of the RI when the risk period is misspecified. We then propose a novel method that more effectively estimates the optimal risk period and the associated RI of AEs. The new method incorporates information on the functional form of the bias. Efficacy of the proposed approach is illustrated with substantial reduction in bias and variance in simulation studies. The proposed method is illustrated with two SCCS studies to determine the (1) risk of idiopathic thrombocytopenic purpura after measles-mumps-rubella vaccination in children and (2) risk of cardiovascular events after infection-related hospitalizations in older patients on dialysis.

Childhood immune thrombocytopenia: A nationwide cohort study on condition management and outcomes

OBJECTIVES

Nationwide prospective cohort study exploring (i) the factors associated with treatment initiation (vs. watchful waiting) in children with primary immune thrombocytopenia (ITP) followed in routine clinical practice and (ii) the predictors of chronicity at 12 months.

PROCEDURE

Between 2008 and 2013, 23 centers throughout France consecutively included 257 children aged 6 months-18 years and diagnosed with primary ITP over a 5-year period. Data on ITP clinical features along with medical management were collected at baseline and 12 months. Multivariate logistic regressions were used to determine (i) and (ii) as defined above, providing odds ratio (OR) with 95% confidence interval (95% CI).

RESULTS

One hundred thirty-seven (53%) children were males, median age was 4.6 years, median platelet count was 7 × 109/l, and 214 (81%) patients initiated medication. Factors independently associated with treatment initiation included platelet counts <10 × 109/l (P < 0.0001) and mucocutaneous bleeding symptoms at baseline (P < 0.001). At 12 months, data were available for 211 (82%) children, of whom 160 (74%) had recovered. Predictors of chronicity included female gender (OR = 2.2; 95% CI = 1.0-4.8), age ≥10 years (OR = 2.6; 95% CI = 1.1-6.0), and platelet counts ≥10 × 10⁹ /l (OR = 3.2; 95% CI = 1.5-6.9).

CONCLUSIONS

In routine clinical practice, the decision to apply a watchful waiting strategy seems to be driven by platelet counts even in the absence of bleeding symptoms, resulting in treatment being initiated in more than 80% of the children surveyed. Overall, younger children with ITP showed good prognosis, with lower platelet counts and, to a lesser extent, male gender predicting more favorable outcomes.

High-dose Cepharanthin for pediatric chronic immune thrombocytopenia in Japan

BACKGROUND

A nationwide, multicenter and observational study was retrospectively conducted to evaluate the clinical utility of Cepharanthin (CEP) for pediatric patients with chronic immune thrombocytopenia (ITP).

METHODS

Clinical and laboratory data for 46 Japanese patients aged <16 years who were diagnosed as having chronic ITP in 14 hospitals during 2001-2011, and were treated with CEP for >12 months, were analyzed.

RESULTS

Median daily CEP dose was 1 mg/kg (range, 0.12-2 mg/kg). Median platelet count prior to CEP was 20.5 × 10⁹ /L (IQR, 8.3-53.0 × 10⁹ /L), and then significantly increased to 58.5 × 10⁹ /L (IQR, 22.8-115.0 × 10⁹ /L) and 69.0 × 10⁹ /L (IQR, 23.0-134.0 × 10⁹ /L) at 12 and 24 months of treatment, respectively. No life-threatening bleeds or moderate-severe adverse events were reported. Of 38 patients who received both corticosteroids (CS) and CEP, 17 patients (45%) were weaned from CS, and 15 patients (39%) attained the reduced dose of CS. The duration from the start of CEP to the stopping of CS was a median of 413 days (range, 49-1734 days) in patients who were weaned from CS.

CONCLUSIONS

CEP alone or combined with CS was useful for the management of pediatric chronic ITPs.