Natural course of childhood chronic immune thrombocytopenia using the revised terminology and definitions of the international working group: a single center experience

Immune Thrombocytopenia in Finnish Children and Adolescents: A Population-Based Cohort Study

AIM

Immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children. This study aimed to describe the diagnostics, patient characteristics, and treatment strategies regarding children with ITP, as well as identify risk factors for chronic disease.

METHODS

This study included 403 Finnish children aged under 16 years at diagnosis, who were first diagnosed with ITP between 2006 and 2020.

RESULTS

Of the 367/403 patients with complete follow-up data, 242 (65.9%) recovered within three months. Chronic ITP developed in 25.9% of the children. Severe bleeding events occurred in 3.7% of them, with no intracranial bleeding events or deaths reported. Pharmacological treatment was administered to 40.2% of the patients. An elevated risk of chronic ITP was found in the children presenting with an insidious disease onset, female gender, higher age, higher platelet counts, and an absence of recent viral infections. As many as 83.3% of the patients with an insidious disease onset and no recent infections developed chronic ITP.

CONCLUSION

Most of the children with ITP experienced short and uncomplicated disease courses. Chronic illness was more likely when the disease onset was insidious, the platelet count was not extremely low, and there was no recent history of an infection.

Immune thrombocytopenia in adolescents and young adults

Previous guidelines for the treatment of immune thrombocytopenia (ITP) have traditionally focused on a dichotomy between pediatric and adult ITP. Adolescents and young adults (AYAs) do not neatly fit into either the pediatric or adult ITP group. A deeper understanding of ITP's natural history, risk factors for chronicity, and outcomes in AYAs is a crucial first step toward developing tailored treatment algorithms. Such data could form the basis for recommendations targeting this underrepresented yet clinically distinct population. Ultimately, age-adapted trials may improve long-term outcomes, reduce toxicity, and enhance quality of life for AYAs with ITP. The AYAs collaboration-drawing on data from the Pediatric and Adult Registry on Chronic ITP (PARC-ITP), Registre Midi- Pyrénéen-France (CARMEN-France) adult registry in Toulouse, and the National Prospective Cohort for Children with Chronic Autoimmune Cytopenia (OBS'CEREVANCE) in Bordeaux, France-aims to address the information gap in AYAs with ITP. To date, four analyses have been undertaken (using data from 2004 to 2021), each addressing the major clinical aspects of ITP in patients aged 12-25 years: (1) newly diagnosed ITP, (2) chronic disease, (3) refractory courses, and (4) secondary (sITP) forms.

Sustained remission at long term follow-up in adolescents and young adults with chronic primary immune thrombocytopenia

ABSTRACT

Adolescents and young adults (AYAs) with immune thrombocytopenia (ITP) exhibit distinct clinical features and needs, defying categorization as either adults or children. Previous findings revealed a 50% risk of chronic disease at 12 months, yet the long-term course remains unclear. This study aimed to delineate the clinical and laboratory characteristics of AYAs with chronic primary ITP. Data from patients aged 12 to 25 years with chronic disease at 1 year were extracted from 3 registries (Pediatric and Adult Registry on Chronic ITP, CEREVANCE, and Cytopénies Auto-immunes Registre Midi-Pyrénéen), covering the period from 2004 to 2021. Sustained complete remission off treatment (SCROT) occurring beyond 12 months was defined as platelet count of >100 × 109/L without treatment for at least 12 months, independently of the previous treatment strategy. A total of 427 AYAs (64% female) with chronic primary ITP were included. Clinical information was available for ∼100% of patients at initial diagnosis and at 6- and 12-month follow-ups (FUs); and for 88%, 77%, and 59% at 24, 36, and 48 months, respectively. Over time, clinical features improved gradually, with fewer patients requiring treatment. Throughout the FU period, second-line drug use increased steadily among treated patients, without affecting the need for corticosteroids and IV immunoglobulins. The proportion of new patients achieving SCROT at 24-, 36-, and 48-month FU was 10% (38/375), 9.5% (31/327), and 12% (30/250), respectively, including 23 who underwent splenectomy. AYAs achieving SCROT between 12 and 36 months displayed higher platelet counts in the first year (excluding the initial period) and received fewer IV immunoglobulin treatments beyond 12 months compared with those with ongoing disease.

Predictors for spontaneous remission in childhood chronic immune thrombocytopenia

This study examined the factors associated with spontaneous remission in children with chronic immune thrombocytopenia (ITP). We retrospectively analyzed the medical records of patients diagnosed with ITP from January 1988 to December 2019 at our institute. A total of 104 children with chronic ITP were identified. The median follow-up time from diagnosis of chronic ITP was 3.6 years (IQR 1.2-8.3, range 0.1-31.4). Fifteen (14.4%) patients with severe symptoms received specific platelet-elevating therapies, including splenectomy, rituximab, and thrombopoietin receptor agonists. Seven of them achieved remission. Among the patients with a platelet count < 30 × 109/L at the time of diagnosis of chronic ITP, those who received specific platelet-elevating therapies had a higher remission rate compared to those who did not (HR: 4.66, 95% CI: 1.36-16.0). Sixteen patients (15.4%) developed systemic lupus erythematosus, 46 (44.2%) still had thrombocytopenia after a median follow-up of 6.8 years, and 42 (40.4%) achieved remission with a median time to remission of 2.0 years (IQR 0.6-4.1, range 0.1-15.7). The two independent predictive factors for spontaneous remission in childhood chronic ITP were platelet counts > 30 × 109/L at the time of diagnosis of chronic ITP (HR: 3.16, 95% CI: 1.51-6.62) and persistently negative ANA at follow-up (HR: 6.12, 95% CI: 1.46-25.7). The cumulative probabilities of spontaneous remission at 10 years post-diagnosis of chronic ITP were 72.2% for patients without risk factor compared to 0% for patients with two risk factors.

Updated international consensus report on the investigation and management of primary immune thrombocytopenia

Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.

Clinical characteristics and treatment courses for cytomegalovirus-associated thrombocytopenia in immunocompetent children after neonatal period

Background

Cytomegalovirus (CMV) causes severe diseases in premature infants and immunocompromised hosts, and antiviral therapy is often required for disease control. However, the clinical manifestations and treatment courses for CMV-associated thrombocytopenia in immunocompetent children are unclear.

Methods

Medical records of the children who suffered from thrombocytopenia, and showed positive CMV polymerase chain reaction and CMV-like symptoms were retrospectively analyzed at three university hospitals in Daegu from January 2000 to March 2017. Patients suffering from leukemia, immunodeficiency, and other infections were excluded.

Results

Among 1,065 children with thrombocytopenia, 29 (2.7%) displayed CMV-associated thrombocytopenia. The median age at diagnosis was 15 months and the median platelet count was 26,000/µL. They were classified into the CMV-induced thrombocytopenia (23/29) and CMV-related secondary immune thrombocytopenia (ITP, 6/29) groups. Fourteen subjects had hepatic dysfunction, four had Evans syndrome, two had pneumonitis, and one had gastritis. IVIG was used for 21 patients, and six patients among them showed recurrence, for whom IVIG or antiviral therapy was used. All, except one, recurrent or chronic cases belonged to the CMV-induced thrombocytopenia group. Antiviral therapy was used more frequently for the CMV-induced thrombocytopenia group (8/23, 34.8%) than for the CMV-related secondary ITP group (0/6); however, the results were not statistically significant (P=0.148).

Conclusion

CMV is a rare but unique etiology of thrombocytopenia, and observed even in healthy children after the neonatal period. About one-third patients need antiviral therapy for disease control. Further, CMV-induced thrombocytopenia is more complex than CMV-related secondary ITP.

High Remission Rate of Chronic Immune Thrombocytopenia in Children: Result of 20-Year Follow-Up

PURPOSE

This study examined the outcomes of children with chronic immune thrombocytopenia (ITP).

MATERIALS AND METHODS

We retrospectively analyzed the medical records of all patients diagnosed with ITP from January 1992 to December 2011 at our institution.

RESULTS

A total of 128 patients (64%) satisfied the criteria for newly diagnosed ITP, 31 (15%) for persistent ITP, and 41 (21%) for chronic ITP. The median age at diagnosis was 4.5 years (range, 1 month to 18 years). The median platelet count at diagnosis was 32×10⁹/L. A comparison of the initial treatment data from 2001 to 2011 with those from 1992 to 2000 showed that the number of bone marrow examinations decreased, whereas observation increased. Chronic ITP presented at an older age than newly diagnosed and persistent ITP (6.6 years vs. 3.8 years vs. 4.1 years, respectively); however, the difference did not reach statistical significance (p=0.17). The probability of complete remission of chronic ITP was 50% and 76% at 2 and 5 years after diagnosis, respectively. Patients aged <1 year at diagnosis had a significantly better prognosis than did older patients (hazard ratio, 3.86; p=0.02).

CONCLUSION

Children with chronic ITP showed a high remission rate after long-term follow-up. This study suggests that invasive treatments such as splenectomy in children with chronic ITP can be delayed for 4 to 5 years if thrombocytopenia and therapeutic medication do not affect the quality of life.

Association of CD4(+)CD25(+)FoxP3(+) regulatory T cells with natural course of childhood chronic immune thrombocytopenic purpura

PURPOSE

The purpose of this study was to determine the frequency of CD4(+)CD25(+)FoxP3(+) regulatory T cells (Treg) in the peripheral blood of patients with childhood chronic immune thrombocytopenic purpura (ITP) exhibiting thrombocytopenia and spontaneous remission. The findings of this study indicate the possibility of predicting spontaneous recovery and pathogenesis of childhood chronic ITP.

METHODS

Eleven children with chronic ITP (seven thrombocytopenic and four spontaneous remission cases; mean age, 8.8 years; range, 1.7-14.9 years) were enrolled in this study. Five healthy children and eight healthy adults were included as controls. The frequency of Treg was evaluated by flow cytometry in the peripheral blood.

RESULTS

In this study, four patients (36%) achieved spontaneous remission within 2.8 years (mean year; range, 1.0-4.4 years). The frequency of Treg was significantly lower in patients with persisting thrombocytopenia (0.13%±0.09%, P<0.05), than that in the patients with spontaneous remission (0.30%±0.02%), healthy adults controls (0.55%±0.44%), and healthy children controls (0.46%±0.26%). A significantly positive correlation was found between the frequency of Treg and the platelet count in children.

CONCLUSION

These data suggest that a lower frequency of Treg contributes to the breakdown of self-tolerance, and may form the basis for future development of specific immunomodulatory therapies. Furthermore, Treg frequency has prognostic implication toward the natural course and long-term outcomes of childhood chronic ITP.