Clinical experience with CD64-directed immunotherapy. An overview

The class I IgG receptor (Fc gamma RI or CD64 receptor), which is present on key cytotoxic effector cells, has been shown to initiate the destruction of tumor cells in vitro and has been hypothesized to play a role in the destruction of antibody-coated cells such as platelets in idiopathic thrombocytopenia purpura (ITP). This overview summarizes the clinical experience with CD64-directed immunotherapy in cancer patients with the bispecific antibodies MDX-447 [humanized Fab anti-CD64 x humanized Fab anti-(epidermal growth factor receptor, EGFR)] and MDX-H210 (humanized Fab anti-DC64 x Fab anti-HER2/neu), and with the anti-CD64 monoclonal antibody (mAB) MDX-33 (H22) in the modulation of monocyte CD64 in vivo. In an ongoing phase I/II open-label trial with progressive dose escalation (1-15 mg/m2), patients with treatment refractory EGFR-positive cancers (renal cell carcinoma (RCC), head and neck, bladder, ovarian, prostate cancer and skin cancer) are treated weekly with intravenous MDX-447, with and without granulocyte-colony-stimulating factor (G-CSF). MDX-447 has been found to be immunologically active at all doses, binding to circulating monocytes and neutrophils (when given with G-CSF), causing monocytopenia and stimulating increases in circulating plasma cytokines. MDX-447 is well tolerated, the primary toxicities being fever, chills, blood pressure lability, and pain/ myalgias. Of 36 patients evaluable for response, 9 have experienced stable disease of 3-6 month's duration. The optimal dose and the maximal tolerated dose (MTD) have yet to be defined; dose escalation continues to define better the dose, toxicity, and the potential therapeutic role of this bispecific antibody. Three MDX-H210 phase II trials are currently in progress, all using the intravenous dose of 15 mg/m2 given with granulocyte/macrophage (GM-CSF). These consist of one trial each in the treatment of RCC patients, patients with prostate cancer, and colorectal cancer patients, all of whom have failed standard therapy. At the time of writing, 11 patients have been treated in these phase II trials. Four patients have demonstrated antitumor effects. Patients demonstrating responses include 2 with RCC and 2 with prostate cancer. One RCC patient has had a 54% reduction in size of a hepatic metastatic lesion and the other has had a 49% decrease in the size of a lung metastasis with simultaneous clearing of other non-measurable lung lesions. Regarding the two patients with prostate cancer, one has had a 90% reduction in serum prostate-specific antigen (PSA; 118-11 ng/ml), which has persisted for several months; the other patient with prostate has had a 70% reduction of serum PSA (872 ng/ml to 208 ng/ml) within the first month of treatment. Both patients have also demonstrated symptomatic improvement. In a completed phase I and in ongoing phase I/II clinical trials, patients with treatment-refractory HER2/neu positive cancers (breast, ovarian, colorectal, prostate) have been treated with MDX-H210, which has been given alone and in conjunction with G-CSF, GM-CSF, and interferon gamma (IFN gamma). These trials have been open-label, progressive dose-escalation (0.35-135 mg/m2) studies in which single, and more often, multiple weekly doses have been administered. MDX-H210 has been well tolerated, with untoward effects being primarily mild-to-moderate flu-like symptoms. The MTD has not yet been defined. MDX-H210 is immunologically active, binding to circulating monocytes, causing monocytopenia, as well as stimulating increases in plasma cytokine levels. Furthermore, some patients have evidence of active antitumor immunity following treatment with MDX-210. Antitumor effects have been seen in response to MDX-H210 administration; these include 1 partial, 2 minor, and 1 mixed tumor response; 15 protocol-defined stable disease responses have occurred. (ABSTRACT TRUNCATED)

Defining signal transduction by inositol phosphates

Ins(1,4,5)P(3) is a classical intracellular messenger: stimulus-dependent changes in its levels elicits biological effects through its release of intracellular Ca(2+) stores. The Ins(1,4,5)P(3) response is "switched off" by its metabolism to a range of additional inositol phosphates. These metabolites have themselves come to be collectively described as a signaling "family". The validity of that latter definition is critically examined in this review. That is, we assess the strength of the hypothesis that Ins(1,4,5)P(3) metabolites are themselves "classical" signals. Put another way, what is the evidence that the biological function of a particular inositol phosphate depends upon stimulus dependent changes in its levels? In this assessment, examples of an inositol phosphate acting as a cofactor (i.e. its function is not stimulus-dependent) do not satisfy our signaling criteria. We conclude that Ins(3,4,5,6)P(4) is, to date, the only Ins(1,4,5)P(3) metabolite that has been validated to act as a second messenger.

Treatments for Primary Immune Thrombocytopenia: A Review

Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of "chronic refractory ITP" is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.

Response to steroids predicts response to rituximab in pediatric chronic immune thrombocytopenia

BACKGROUND

Treatment choice in pediatric immune thrombocytopenia (ITP) is arbitrary, because few studies are powered to identify predictors of therapy response. Increasingly, rituximab is becoming a treatment of choice in those refractory to other therapies.

METHODS

The objective of this study was to evaluate univariate and multivariable predictors of platelet count response to rituximab. After local IRB approval, 565 patients with chronic ITP enrolled and met criteria for this study in the longitudinal, North American Chronic ITP Registry (NACIR) between January 2004 and October 2010. Treatment response was defined as a post-treatment platelet count ≥ 50,000/µl within 16 weeks of rituximab and 14 days of steroids. Treatment response data were captured both retrospectively at enrollment and then prospectively.

RESULTS

Eighty (14.2%) patients were treated with rituximab with an overall response rate of 63.8% (51/80). Univariate correlates of response to rituximab included the presence of secondary ITP and a positive response to steroids. In multivariable analysis, response to steroids remained a strong correlate of response to rituximab, OR 6.8 (95% CI 2.0-23.0, P = 0.002). Secondary ITP also remained a strong predictor of response to rituximab, OR 5.6 (95% CI 1.1-28.6, P = 0.04). Although 87.5% of patients who responded to steroids responded to rituximab, 48% with a negative response to steroids did respond to rituximab.

CONCLUSION

In the NACIR, response to steroids and presence of secondary ITP were strong correlates of response to rituximab, a finding not previously reported in children or adults.

Response to mercaptopurine for refractory autoimmune cytopenias in children

BACKGROUND

Several treatment strategies are available for children with severe immune thrombocytopenic purpura (ITP) and other immune cytopenias refractory to initial therapies. 6-Mercaptopurine (6MP) is one option, however it has not been well studied in children, especially as a single agent, and no pediatric case series have been reported since 1970.

PATIENTS AND METHODS

We reviewed the experience at our institution over 8 years, using 6MP as a steroid sparing treatment for children with ITP, auto-immune hemolytic anemia (AIHA) or Evans syndrome. A total of 29 pediatric patients were treated with 6MP from 2000 to 2007.

RESULTS

Response was defined as a rise in hemoglobin by at least 1.5 g/dl and to a level of 10 g/dl or greater in patients treated for anemia, or a platelet count >or=50 x 10(9)/L in patients treated for thrombocytopenia. We found an overall response rate of 83% among all patients. Fourteen percent of patients stopped drug because of side effects.

CONCLUSIONS

These results suggest that 6MP can be an effective single-agent treatment for refractory immune cytopenias in children. Prospective studies are warranted to determine long-term efficacy and toxicity and to more clearly define patient populations most likely to respond.

Trial protocol: a multicentre randomised trial of first-line treatment pathways for newly diagnosed immune thrombocytopenia: standard steroid treatment versus combined steroid and mycophenolate. The FLIGHT trial

INTRODUCTION

Immune thrombocytopenia (ITP) is an autoimmune condition that may cause thrombocytopenia-related bleeding. Current first-line ITP treatment is with high-dose corticosteroids but frequent side effects, heterogeneous responses and high relapse rates are significant problems with only 20% remaining in sustained remission with this approach. Mycophenolate mofetil (MMF) is often used as the next treatment with efficacy in 50%-80% of patients and good tolerability but can take up to 2 months to work.

OBJECTIVE

To test the hypothesis that MMF combined with corticosteroid is a more effective first-line treatment for immune thrombocytopenia (ITP) than current standard of corticosteroid alone.

METHODS AND ANALYSIS

DesignMulticentre, UK-based, open-label, randomised controlled trial.

SETTING

Haematology departments in secondary care.

PARTICIPANTS

We plan to recruit 120 patients >16 years old with a diagnosis of ITP and a platelet count <30x10⁹/L who require first-line treatment. Patients will be followed up for a minimum of 12 months following randomisation.

PRIMARY OUTCOME

Time from randomisation to treatment failure defined as platelets <30x10⁹/L and a need for second-line treatment.

SECONDARY OUTCOMES

Side effects, bleeding events, remission rates, time to relapse, time to next therapy, cumulative corticosteroid dose, rescue therapy, splenectomy, socioeconomic costs, patient-reported outcomes (quality of life, fatigue, impact of bleeding, care costs).

ANALYSIS

The sample size of 120 achieves a 91.5% power to detect a doubling of the median time to treatment failure from 5 to 10 months. This will be expressed as an HR with 95% CI, median time to event if more than 50% have had an event and illustrated with Kaplan-Meier curves. Cost-effectiveness will be based on the first 12 months from diagnosis.

ETHICS AND DISSEMINATION

Ethical approval from NRES Committee South West (IRAS number 225959). EudraCT Number: 2017-001171-23. Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03156452.

Applicability of 2009 international consensus terminology and criteria for immune thrombocytopenia to a clinical pediatric population

BACKGROUND

Since pediatric immune thrombocytopenia (ITP) is relatively infrequent, comparisons among clinical studies are critical but have previously been limited by differences in terminology. In 2009, an international working group (IWG) developed consensus criteria to enhance comparability in future studies in adults and children.

METHODS

We performed a retrospective medical record review of all pediatric ITP patients seen at a single children's hospital with a first visit between 2003 and 2010 and applied both historical (criteria(Hist) ) and IWG (criteria(IWG) ) ITP criteria to available clinical data.

RESULTS

Among the 505 patients seen for ITP over 7 years, 98% could be classified as "acute" or "chronic" ITP using the criteria(Hist) , while only 90.7% could be classified as "newly diagnosed," "persistent," or "chronic" ITP using the criteria(IWG) (P < 0.01). Only 33.7% met criteria(IWG) for severe ITP, whereas 77.4% met criteria(Hist) for severe ITP. A striking difference was that overall response to therapies was lower if the criteria(IWG) were used rather than the criteria(Hist) , particularly for IVIG (55.4% vs. 70%, P = 0.02) and rituximab (35.3% vs. 83.3% P = 0.05). Only 2 subjects (0.4%) met the criteria(IWG) for refractory ITP.

CONCLUSIONS

Most ITP patients could easily be classified using the 2009 criteria(IWG) . Limitations to applying the criteria(IWG) included absence of treatment response durations, incomplete definition of pediatric "refractory ITP," and exclusion of secondary ITP. Nevertheless, the criteria(IWG) were more clinically relevant given the reliance on definitions based on bleeding and their ability to be applied prospectively. The utility of using the criteria(IWG) within prospective trials remains to be determined.

The incidence of thrombocytopenia in children with Cornelia de Lange syndrome

Thrombocytopenia was first reported in Cornelia de Lange syndrome (CdLS) by Froster in 1993. Despite early reports, thrombocytopenia has been rarely reported in this disorder. We performed a retrospective analysis of a large cohort of patients with CdLS. We calculated prevalence of thrombocytopenia in three subsets of this cohort: the entire cohort (n = 1,740), a subset of subjects with substantial clinical records (n = 695) and a subset of subjects with clinical information regarding platelet counts (n = 85). This analysis revealed that 15 have had thrombocytopenia (18% of those with available blood counts); seven had immune thrombocytopenia (ITP). The reported prevalence of pediatric ITP is between 5 and 13 per 100,000 persons. The prevalence of ITP in this cohort is between 7/1,740 and 7/85, giving a relative risk of ITP of between 30 (CI 12-77) and 633 (CI 259-1,549). Contrary to the reported cases in the literature, none of our patients have had progression of the thrombocytopenia nor have they developed other cytopenias. All 15 patients with thromobocytopenia had CdLS based on clinical criteria. Of the 10 patients tested for mutations in NIBPL, 8 had mutations identified. These data support an increased incidence of thrombocytopenia and ITP in CdLS. Subsequently, patients are at risk for spontaneous hemorrhage, and likely increased risk secondary to the high frequency of self-injurious behavior. Although further studies are needed to better define the scope of the problem and to define the mechanisms of thrombocytopenia in CdLS, we would recommend screening for thrombocytopenia upon diagnosis and at 5-year intervals thereafter.

Newly Diagnosed Idiopathic Thrombocytopenia Post COVID-19 Vaccine Administration

A few individuals are believed to have developed immune thrombocytopenia (ITP) following the administration of the coronavirus disease 2019 (COVID-19) vaccine. This phenomenon has been reported in a few case reports and also in some recent news articles. In this report, we discuss a case of a 54-year-old Caucasian female who presented to the emergency room with life-threatening thrombocytopenia in the setting of de novo ITP following COVID-19 vaccine administration. Due to the relapsing nature of ITP, it is unclear if the patient has achieved complete remission of the disease.

Helicobacter pylori: An Underrated Cause of Immune Thrombocytopenic Purpura. A Comprehensive Review

Idiopathic thrombocytopenic purpura (ITP) is the autoimmune-mediated destruction of platelets. ITP is a diagnosis of exclusion after other identifiable etiologies have been ruled out. After the first report by Gasbarrini et al. (1998) showing rising platelet counts in ITP patients following Helicobacter pylori (HP) eradication therapy, there is growing evidence that highlights the role of HP in triggering ITP. However, the exact pathophysiology of HP-associated ITP is still unclear, but many theories have been implicated in this regard. According to various reports, the postulated mechanisms for the role of HP in cITP include molecular mimicry, increased plasmacytoid dendritic cell numbers, phagocytic perturbation, and variable host immune response to HP virulence factors. One famous theory suggested molecular mimicry between platelet surface antigen and bacterial virulence factor, i.e. cytotoxin-associated gene A (CagA). It is thought that a chronic inflammatory response following an HP infection induces the host autoantibodies' response against CagA, which cross-reacts with platelet surface glycoproteins; therefore, it may accelerate platelet destruction in the host reticuloendothelial system. However, further studies are mandated to better understand the causal link between ITP and HP and study the role of biogeography. Nowadays, it is recommended that every patient with ITP should undergo HP diagnostic testing and triple therapy should be administered in all those candidates who test positive for HP infection. In our review, there were a few pregnant female ITP patients who took HP eradication therapy mainly after 20 weeks of gestation without maternal or fetal worst outcomes. However, large-scale studies are advisable to study the adverse fetal outcomes following triple therapy use.

Immune Thrombocytopenic Purpura and Intracerebral Hemorrhage, Incidence, and Mortality

INTRODUCTION

Intracerebral hemorrhage (ICH) is a devastating complication of immune thrombocytopenic purpura (ITP). Using a large database, we sought to determine its incidence and mortality.

METHODS

We used a de-identified database (TriNetX) to gather information on patients with ITP with subsequent ICH (cohort 1), propensity score-matched with patients with ITP and no ICH (cohort 2). Primary endpoint was mortality, with secondary endpoints of percutaneous endoscopic gastrostomy (PEG) placement, craniotomy, palliative care encounters, intensive care unit (ICU) management, seizure, falls, pulmonary embolism (PE), myocardial infarction (MI), deep venous thrombosis (DVT), ischemic stroke (IS), and other venous embolism and thrombosis (VTE).

RESULTS

Incidence of ICH in patients with ITP was 1.540% in all ages, and 0.774% in those under age 18. After matching, 942 patients from each cohort were identified. Mean age was 58.3 years versus 61.2 years in cohort 1 and 2, respectively. Mortality rate was 34.076% vs. 20.17% (p <0.0001, OR 2.046 with 95% CI 1.661,2.520) at five years. Thirty-day survival was 83.46% vs. 95.17% (p<0.0001), and 365-day survival 68.59% vs. 85.33% (p<0.0001). PEG placement was seen in 21 (2.229%) patients in cohort 1, and less than 10 patients (<1.062%) in cohort 2 (p<0.0464). 2.442% vs. 0% underwent craniotomy (p<0.0001), palliative care was involved in 15.711% vs. 7.962% (p<0.0001), ICU care was seen in 27.389% vs. 11.783% (p<0.0001), with a mean ICU stay of 8.075 vs. 5.812 days (p=0.0537). 6.582% vs. 3.715% had PE (p=0.0049), 7.643% vs. 7.113% experienced MI (p=0.6595), 9.236% vs. 4.883% had DVTs (p=0.0002), 23.673% vs. 5.732% had seizures (p<0.0001), 9.023% vs. 6.582% suffered falls (p=0.0482), 7.537% vs. 3.503% suffered IS (p<0.0001), and 15.074% vs. 8.174% experienced other VTE (p<0.0001).

CONCLUSION

ICH occurs in approximately 1.54% of ITP patients, and is associated with a 34% mortality rate, increased PEG tube placement rates, palliative care involvement, ICU care, craniotomy, PE, IS, DVT, seizures, and falls.

Synchronous Occurrence of Diffuse Large B-cell Lymphoma of the Duodenum and Gastrointestinal Stromal Tumor of the Ileum in a Patient with Immune Thrombocytopenic Purpura

A 64 year-old woman with steroid-dependent immune thrombocytopenia developed anemia. Esophagogastroduodenoscopy revealed the presence of a tumor, which was diagnosed to be diffuse large B-cell lymphoma, in the second portion of the duodenum. ¹⁸F-fluorodeoxy glucose positron emission tomography showed an increased uptake mass in the pelvic cavity as well as in the duodenum. Though the duodenal tumor disappeared after 4 cycles of chemotherapy, the pelvic mass did not shrink in size. As a result, laparoscopic resection of the pelvic tumor was performed and the tumor was histologically diagnosed to be a gastrointestinal stromal tumor. Subsequently, the patient was treated with 2 more cycles of the chemotherapy. Eventually, thrombocytopenia completely resolved.

Severe Immune Thrombocytopenia Post-COVID-19: A Case Report

Immune thrombocytopenia, also called idiopathic thrombocytopenic purpura, is a common cause of thrombocytopenia after viral infections. Even in the second year of the coronavirus disease 2019 (COVID-19) pandemic, our body of knowledge regarding the diverse symptoms and complications of the virus continues to grow and evolve. We present a case of a 48-year-old African American male who came into the emergency department with severe left foot pain. A platelet count of 7x10³/mL was incidentally found on complete blood count (CBC) during the patient's initial workup. The patient had previously been hospitalized for COVID-19 five weeks prior. Further workup did not support any etiology of his thrombocytopenia. Therefore, we gave a presumed diagnosis of idiopathic thrombocytopenic purpura secondary to COVID-19. The patient was treated with corticosteroid resulting in improvement in his platelet count.

Romiplostim and Eltrombopag in Immune Thrombocytopenia as a Second-Line Treatment

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by platelet count less than 100×10⁹/L and an increased risk of bleeding. The risk of bleeding increases in proportion with the degree of thrombocytopenia. Although several medications are used for primary thrombocytopenia treatment, refractoriness remains a concern. Romiplostim and eltrombopag, two relatively new drugs, have been shown to be successful in ITP treatment after standard treatment failure. The current guidelines recommend their use as a second-line treatment. In this article, we have tried to compare which of these two medications is the best option considering clinical effectiveness, cost-effectiveness, adverse effects, and the possibility of switching between them in case of ineffectiveness. The studies used in this article were found in the PubMed database. All the studies are limited to adults. Based on these studies, both medications seem to be a largely effective, safe option. Romiplostim appears to have slightly fewer adverse effects and higher costs. Switching between thrombopoietin receptor agonists (TRAs) is a successful way to overcome adverse effects and inadequacy according to the currently available literature. We believe that more detailed studies are needed to determine which of these drugs should be considered the first choice, to report long term efficacy and adverse effects, and to determine if treatment guidelines can change regarding the use of TRAs as first-line treatment.

Prevalence of monoclonal gammopathy of uncertain significance in chronic myeloid leukemia: A case report

RATIONALE

The abnormal cell types in chronic myeloid leukemia (CML) and monoclonal gammopathy of uncertain (MGUS) are quite different, being myeloid and plasma cells, respectively. The coexistence of CML and MGUS is an uncommon event, which is seldom reported in literature.

PATIENT CONCERNS

A 52-year-old female was diagnosed with CML in April 2001. From November 2006, the patient started on imatinib mesylate and kept a complete hematologic and cytogenetic response for nearly 11 years. During her follow-up on July 7, 2017, thrombocytopenia (35*109/L) was found. Bone marrow aspiration revealed 6% plasma cell infiltration. Serum immunoelectrophoresis revealed 1.24 g/dL of serum monoclonal (M) protein of IgG-κ type.

DIAGNOSIS

MGUS was diagnosed because of absence of anemia, hypercalcemia, lytic bone lesions, or renal failure. Immune thrombocytopenia (ITP) was also diagnosed in this patient following the detection of antiplatelet autoantibodies. Complex karyotype and missense mutation in PRDM1 were identified.

INTERVENTIONS

Because of her obvious decrease of platelets, she started treatment with thalidomide and prednisone.

OUTCOMES

Three months later, bone marrow aspirate showed disappearance of plasma cells. There developed an abrupt decrease in IgG and the absence of M-spike in serum immunoelectrophoresis. The platelet count kept normal during 1 year follow-up.

LESSONS

Karyotypic event and gene mutation found in this case may be the initiation of disease transformation. Administration of thalidomide and prednisone proved effective in this patient.

Idiopathic Thrombocytopenic Purpura: A Rare Syndrome with Alemtuzumab, Review of Monitoring Protocol

Alemtuzumab, a humanized monoclonal antibody that targets surface molecule CD52, causes rapid and complete depletion of circulating T- and B-lymphocytes through antibody-dependent cell-mediated and complement-mediated cytotoxicity. Alemtuzumab has demonstrated superior efficacy compared to subcutaneous interferon beta-1a (SC IFNB-1a) in patients with multiple sclerosis (MS). Alemtuzumab treatment causes a rare and distinct form of secondary immune thrombocytopenic purpura (ITP), characterized by delayed onset, responsiveness to conventional therapies, and prolonged remission following treatment. In phase two and three clinical trials, the incidence of ITP was higher with alemtuzumab treatment compared to the patients receiving SC IFNB-1a. Here we report a case of ITP occurring two years after the first treatment with alemtuzumab. The patient recovered completely after a timely diagnosis and adequate treatment. Rigorous patient education and careful complete blood count (CBC) monitoring by the physician are critical for early identification and treatment of this potentially fatal disorder.

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.

Omicron-Induced Immune Thrombocytopenia: A Case Report

Coronavirus disease 2019 is a systemic infection that significantly impacts the hematopoietic system and hemostasis. Among the hematological manifestations described, severe and symptomatic thrombocytopenia is rare. Immune thrombocytopenia (ITP), also known as idiopathic thrombocytopenic purpura or immune thrombocytopenic purpura, is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. It is one of the more common causes of thrombocytopenia in otherwise asymptomatic adults. Here, we report the case of a patient who developed ITP after a severe acute respiratory syndrome coronavirus 2 infection to highlight the rarer hematological manifestations of the disease and the changes in treatment.

Immune Thrombocytopenic Purpura and Its Rare Association With a Brucella Infection: A Case Report

Although several factors such as viral and bacterial pathogens, and drugs have been widely reported to be associated with immune thrombocytopenic purpura (ITP), brucellosis is an unusual cause of this disorder. Here, we describe a patient with brucellosis with fever and purpura as the first manifestation of her illness due to immune-mediated severe thrombocytopenia. In this case, ITP responded well to the anti-Brucella treatment with platelet recovery within three days.

Immune Thrombocytopenia Secondary to COVID-19 in a Vitamin B12-Deficient Patient: A Diagnostic Dilemma and Therapeutic Challenge

Immune thrombocytopenia (ITP) caused by infectious and non-infectious conditions has been reported in coronavirus disease 2019 (COVID-19) patients too. Here we present a 64-year-old male patient with post-COVID-19 pneumonia who presented with a gastrointestinal bleed and was found to have severe isolated thrombocytopenia (22,000/cumm) diagnosed as ITP with extensive investigations. He was treated with pulse steroid therapy and later was also given intravenous immunoglobin in view of poor response. The addition of eltrombopag also resulted in a sub-optimal response. He was also having low vitamin B12, and his bone marrow also supported the megaloblastic picture. Hence, injectable cobalamin was added to the regimen, which resulted in a sustained rise in platelet count that reached 78,000/cumm, and the patient got discharged. This shows the possible hindrance to treatment response by concomitant B12 deficiency. Vitamin B12 deficiency is not an uncommon entity and should be tested in those who show no or slow response to thrombocytopenia.

Aggressive Perioperative Management for Immune Thrombocytopenic Purpura in a Patient Undergoing Open Heart Surgery: A Correct Strategy in an Emergent Patient?

Immune thrombocytopenic purpura (ITP) is an autoimmune pathology that causes thrombocytopenia. This can become extremely troublesome when dealing with the rare clinical scenario of having to operate a highly invasive procedure on patients with thrombocytopenia. We report a case of a 66-year-old male with multiple comorbidities, including ITP, who underwent coronary artery bypass grafting (CABG) with an aortic valve replacement (AVR). He deteriorated rapidly, prompting urgent procedures. Little to no literature exists on the treatment plan for a critical patient with ITP who is about to undergo an open heart surgery. Our goal was to aggressively treat the patient with prednisolone, azathioprine, and platelets in the short preoperative time in order to maximize the prognosis. Our patient remained stable postoperatively, developed no complications, and was discharged successfully.

Recurrent Evans Syndrome in a Patient With 22q11.2 Deletion Syndrome: An Uncommon Hematological Presentation

We discuss the case of a three-year-old female patient who presented with a severe episode of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA), confirming a diagnosis of Evans syndrome (ES). Over time, she continued to have several episodes of recurrent ITP until, several years later, she experienced a recurrent severe, refractory ES episode. Initially, she responded well to conventional treatment with steroids and intravenous immunoglobulin (IVIG); however, during later episodes, she required anti-CD20 therapy (rituximab). Due to peculiar facies and severe clinical presentation, an underlying immune dysregulation was suspected, which was later confirmed to be 22q11.2 deletion syndrome (22q11.2DS). Over time, her baseline immunoglobulin production decreased significantly. After monthly IVIG replacement, she had a marked reduction in ITP or AIHA events. 22q11.2DS is a frequently underdiagnosed primary immune disorder (PID). Low immunoglobulin production and recurrent ES are infrequent events associated with 22q11.2DS. This condition might cause profound immune dysregulation, predisposing patients to immune-related hematological dyscrasias that still need further research to be fully understood and characterized. We describe a case of 22q11.2DS and recurrent ES episodes, which involves a 13-year history of longitudinal follow-up care.