Management of immune thrombocytopenia: Korean experts recommendation in 2017

Immune Thrombocytopenia Induced by Helicobacter pylori Infection: A Case Report and Literature Review

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by the production of autoantibodies targeting platelet membrane antigens, leading to platelet destruction by the reticuloendothelial system. This results in a significant drop in platelet count to 100 × 10⁹/L or lower due to the formation of autoantibodies and immune complexes. Some studies suggest a potential link between Helicobacter pylori infection and ITP. This report presents a case of ITP in a patient with an H. pylori infection. To our knowledge, this is one of the unique and interesting reported cases of such a severe platelet deficiency, where the platelet count dropped to 1,000 cells/µL in the presence of an aggressive H. pylori infection. A 46-year-old male was admitted with mild gum bleeding and petechiae on his lower limbs. His medical history included chronic diabetes mellitus, dyslipidemia, and hypertension, though his clinical and vital signs were normal. Laboratory tests revealed a critically low platelet count of 3,000 cells/µL, leading to a provisional diagnosis of ITP. The patient was started on intravenous (IV) methylprednisolone (1 g for three days), IV immunoglobulin (0.4 g/kg for five days), proton pump inhibitors, calcium, and vitamin D supplements. However, there was no significant response to the treatment. Additional immunological and viral tests yielded negative results. Given this, an H. pylori test was conducted, which confirmed an infection. The patient was started on H. pylori eradication therapy. The platelet count improved to 48,000 cells/µL, but it dropped again to 1,000 cells/µL after a few days. Various treatment strategies were implemented to manage both ITP and H. pylori. After two months, the H. pylori urea breath test returned negative, and the patient's platelet count normalized. The patient was maintained on folic acid (5 mg daily) and eltrombopag (50 mg daily), with regular hematology follow-ups ensuring stable platelet levels. This case underscores a rare presentation of ITP associated with severe thrombocytopenia (1,000 cells/µL) and aggressive H. pylori infection. The findings emphasize the importance of considering H. pylori in the differential diagnosis of ITP and highlight the necessity of identifying underlying causes for effective treatment.

Refractory immune thrombocytopenia treated with low-dose decitabine combined with recombinant human thrombopoietin or eltrombopag: Two case reports

RATIONALE

Immune thrombocytopenia (ITP) is an autoimmune-mediated disorder caused by antibody-mediated platelet destruction and impaired platelet production by megakaryocytes. Treating refractory ITP remains a significant challenge.

PATIENT CONCERNS AND DIAGNOSES

We report 2 patients with refractory ITP.

INTERVENTIONS AND OUTCOMES

Two patients received low-dose decitabine combined with recombinant human thrombopoietin or eltrombopag. Platelet counts in both patients increased to within the normal range.

LESSONS

Low-dose decitabine combined with recombinant human thrombopoietin or eltrombopag may exert a synergistic effect in the treatment of refractory ITP.

Comparison of hematologic parameters, serum electrolytes, and lipid profiles among dyspeptic patients with and without Helicobacter pylori infection attending Jimma Medical Center, Jimma, South West Ethiopia

BACKGROUND

About half of the world's populations are infected with Helicobacter pylori, which may create atherogenic lipid profiles and contribute to atherosclerosis and related cardiovascular disease. Furthermore, it has been connected to hematological symptoms like anemia. Even though the high prevalence of H.pylori and its associated complications, including cardiovascular disease and anemia, in Ethiopia, there is little data regarding the risk factors associated with H.pylori infection, such as hematologic parameters, electrolyte imbalances, and lipid profiles.

METHODS

A comparative cross-sectional study design with a consecutive sampling technique was employed at Jimma Medical Center among 108 dyspeptic patients. Five (5) ml of blood samples were collected from each participant, and serum was extracted and analyzed using a COBAS 6000 core for the lipid and electrolyte, and whole blood was used with a SYSMEX XN 550 to determine hematological parameters. Data were entered in to Epi-data version 4.6 and exported to SPSS version 25 for analysis. Simple descriptive statistics and chi-square test were used to present the socio-demographic characteristics of the study subjects. Student t-test was used for data comparison and p-value < 0.05 was considered statistically significant.

RESULTS

H.pylori infected patients had significantly decreased levels of red blood cell count (p = 0.002), hemoglobin (p = 0.012), mean corpuscular hemoglobin concentration (p < 0.001), platelet count (p = 0.001), and sodium level (p = 0.006) when compared to the uninfected group. However, total cholesterol (p = 0.001), and low density lipoprotein (p = 0.021) were increased in H.pylori infected patients when compared to the uninfected group.

CONCLUSIONS

This study revealed that H.pylori infection can cause derangements of hematologic parameters, electrolyte imbalances, and alterations of lipid parameters which considered as risk factors for anemia and cardiovascular diseases.

The Outcomes and Adverse Drug Patterns of Immunomodulators and Thrombopoietin Receptor Agonists in Primary Immune Thrombocytopenia Egyptian Patients with Hemorrhage Comorbidity

Immune thrombocytopenia (ITP) treatment has evolved recently. However, none of the treatments have only benefits without drawbacks. This study aimed to compare the clinical outcomes and adverse drug patterns of Eltrombopag, Romiplostim, Prednisolone + Azathioprine, High Dose-dexamethasone (HD-DXM) (control group), and Rituximab in primary ITP Egyptian patients. All patients were initiated with corticosteroids, HD-DXM, as a first-line treatment for the first month immediately following diagnosis. Four hundred sixty-seven ITP patients were randomly assigned to five groups. The outcome measures were judged at baseline, at the end of treatment (6 months), and after an additional 6-month free treatment period. The follow-up period for which relapse is noted was 6 months after the end of treatment. Eltrombopag and Romiplostim resulted in a significantly higher incidence of sustained response than Rituximab, HD-DXM, and Prednisolone + Azathioprine (55.2% and 50.6% vs. 29.2%, 29.1%, and 18%, respectively; p-value < 0.001). More patients on immunomodulators (Prednisolone+ Azathioprine, HD-DXM, and Rituximab) relapsed than those on Romiplostim and Eltrombopag (81.9%, 70.8%, and 70.7% vs. 49.3%, and 44.7%, respectively; p-value < 0.01). We also describe 23 reports of pulmonary hypertension with Prednisolone+ Azathioprine and 13 reports with HD-DXM. The thrombotic events occurred in 16.6% and 13% of patients who received Eltrombopag and Romiplostim treatment, respectively. Most patients had at least one or two risk factors (92.8% of cases). Corticosteroids are effective first-line therapy in primary ITP patients. However, relapse is frequent. Eltrombopag and Romiplostim are safer and more effective than Prednisolone, HD-DXM, and Rituximab. They might be reasonable beneficial options after a one-month HD-DXM regimen.

Eradication therapy may decrease the risk of immune thrombocytopenia after Helicobacter pylori infection: a retrospective cohort study in Taiwan

BACKGROUND

Helicobacter pylori (HP) eradication therapy (HPE) is recommended for patients with unexplained immune thrombocytopenia (ITP); however, the role of HPE in preventing ITP in patients with HP infection remains unclear. Therefore, this study was designed to clarify it.

METHODS

This study was conducted at a tertiary medical center and included all adult patients with HP infection between January 1, 2016 and December 31, 2018. We compared the risk of developing ITP between patients with and without HPE. All patients were followed up until December 31, 2020.

RESULTS

After excluding patients with thrombocytopenia, 1995 adult patients with HP infection, including 1188 patients with HPE and 807 patients without HPE, were included in this study. The mean age of the patients with HPE was 57.9 years, whereas that of those without HPE was 61.6 years. The percentage of males was 56% in patients with HPE and 59% in those without HPE. Patients without HPE had a higher risk of ITP than those with HPE after adjusting for age, sex, the Charlson Comorbidity Index, and comorbidities [adjusted odds ratio (OR) 1.76; 95% confidence interval (CI) 1.16-2.68]. Stratified analyses showed that the higher risk was found only in males (adjusted OR: 1.70; 95% CI 1.03-2.80). In addition to HPE, male sex and anemia were independent predictors of ITP in patients with HP infection.

CONCLUSION

This study showed that adult patients with HP infection not receiving HPE had a higher risk of developing ITP. We suggest that HPE should be considered, particularly in males and those who have anemia, to prevent ITP.

Predictive Value of B reg and Serum IL-10 Concentration Levels for Acute ITP Progression to Chronic Phase

INTRODUCTION

Pediatric immune thrombocytopenia (ITP) is a potentially life threating autoimmune disorder with different responses to therapy and different bleeding phenotypes in critical organs. The molecular basis for the variable response has not yet been fully elucidated. This study was designed to address the predictive value of regulatory B-cell (B reg ) count and interleukin-10 (IL-10) serum levels for acute ITP patients who progress to chronic phase. The present study included 80 children with acute ITP )38 males and 42 females (with median age of 8 years and 40 matched healthy controls. Assessment of B reg (CD19 + CD24 hi CD38 hi ) was carried out by a multicolor flowcytometry, however, IL-10 serum levels were evaluated by enzyme-linked immunosorbent assay. A significant reduction of B reg percentage and a significant increase in serum IL-10 levels were identified in children with acute ITP as compared with controls ( P <0.001 for both). Fourteen ITP patients passed to chronic phase, while 66 patients achieved remission within 6 months. The absolute B reg was significantly lower, while IL-10 was significantly higher in patients with acute ITP who progressed to chronic phase in comparison with acute ITP patients who achieved complete remission. Cox proportional hazards for ITP chronicity revealed that IL-10 OR was 2.46 (confidence interval: 1.42-4.27; P =0.001) and absolute B reg OR was 0.147 (confidence interval: 0.128-0.624; P =0.005) in the peripheral blood. Therefore, they could predict chronicity in ITP cases.

CONCLUSION

Reduced B reg count and elevated IL-10 levels in patients with acute ITP at diagnosis can predict chronicity.

Management of immune thrombocytopenia: 2022 update of Korean experts recommendations

Despite the availability of therapies to treat patients with immune thrombocytopenia (ITP), there is currently little data from randomized trials to assist clinicians in managing patients. The evidence-based guidelines of the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) are intended to support patients and physicians in the management of ITP. Experts from the KSHAAWP discussed and described this guideline according to the current treatment situation for ITP in Korea and finalized the guidelines. The expert panel recommended the management of ITP in adult and pediatric patients with newly diagnosed, persistent, and chronic disease refractory to first-line therapy with minor bleeding. Management approaches include observation and administration of corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, and thrombopoietin receptor agonists. Currently, evidence supporting strong recommendations for various management approaches is lacking. Therefore, a large focus was placed on shared decision-making, especially regarding second-line treatment.

Helicobacter pylori induced Immune Thrombocytopenic Purpura and perspective role of Helicobacter pylori eradication therapy for treating Immune Thrombocytopenic Purpura

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterised by production of autoantibodies against platelet surface antigens. Recent studies have demonstrated a paramount association of ITP and Helicobacter pylori (H-pylori) infection with significant rise in platelet count following H-pylori eradication therapy. The H-pylori infection induced ITP is validated by many proposed mechanisms such as molecular mimicry due to production of autoantibodies against H-pylori surface virulent factors (CagA) and cross reactivity of these antibodies with platelet surface antigens (GP IIb/IIIa, GP Ib/IX, and GP Ia/IIa), phagocytic perturbation due to enhanced phagocytic activity of monocytes, enhanced dendritic cell numbers and response, platelets aggregation due to presence of anti- H-pylori IgG and von Willebrand factor (vWf) and finally host immune response against H-pylori virulent factors CagA and VacA leading to ITP. The effectiveness of H-pylori eradication therapy has also been demonstrated with platelet count being used as a predictive factor for assessment of treatment efficacy. Out of 201 patients 118 were responding to the triple therapy and remaining 83 patients were non-responders, showing the response rate of 58.7%. Out of 118 responders 69 patients were showing complete response (CR) and 49 were showing partial response (PR) to the H-pylori eradication therapy. However, more studies are required to elucidate this association and treatment efficacy.

Helicobacter pylori eradication affects platelet count recovery in immune thrombocytopenia

Helicobacter pylori (H. pylori) infection is on the rise as a cause of immune thrombocytopenia (ITP). It has been suggested that platelet recovery can be achieved following successful microbial eradication, although, the exact pathophysiology has yet to be fully elucidated. This study evaluated the long-term effects of H. pylori eradication monotherapy on platelet count recovery in patients with ITP. H. pylori eradication was analysed in 61 ITP patients. Patients who maintained a complete response (CR) for more than six months were classified as sustained responders (SR). The prevalence of H. pylori infection was 54.3% (75/138), and the success rate of eradication with first-line therapy was 71.4% (35/49). Patients who had achieved a CR at 2 months maintained a higher platelet count thereafter. At 1 year following eradication, platelet counts had increased 2.78 times in the eradicated group, 1.36 times in the sustained infection group, and 1.33 times in the no infection group compared with the baseline (P = 0.016).

Report of a 'consensus' on the lines of therapy for primary immune thrombocytopenia in adults, promoted by the Italian Gruppo di Studio delle Piastrine

Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1. classification of four 'lines of therapy'; 2. acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3_I . practicability of splenectomy; 3_Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4_a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.

Idiopathic Aplastic Anemia in Children and Adults: Diagnosis, Treatments, and Management - A Review

Aplastic Anemia (AA) is also known as idiopathic aplastic anemia (IAA) and the production of new blood cells ceases in AA, which leads to an abnormal hematological syndrome such as pancytopenia and suppression of hypo-cellular bone marrow. The pathophysiology of AA in most cases is immune-mediated and is stimulated by type 1 cytotoxic T cells. Reliable early diagnostic tests of IAA are not yet available, therefore most of the cases are identified in advanced stages. Recently, abnormal immune response and hematopoietic cell deficiencies are defined genetically, such as in target cells of telomere repair gene mutations and by the dysregulation of T-cell activation pathways. Importantly, anti-thymocyte globulins and cyclosporine-associated immunosuppression are successful treatments for restoring blood cell production in most of the cases, however, clonal hematologic diseases remain challenging. In the current review, we have discussed the common practices in the treatment, pathophysiology, diagnosis, and management of AA.

Preventing infectious complications when treating non-malignant immune-mediated hematologic disorders

Immunosuppressants, targeted antibody therapies, and surgical splenectomy are amongst the treatment choices for immune-mediated non-malignant hematologic disorders, with infection being the most common non-hematological adverse event from these therapies. Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection, including opportunistic infections. Screening and antimicrobial prophylaxis against tuberculosis, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia, are indicated in selected patients on steroids and with certain risk factors for infection. Rituximab is associated with hepatitis B virus reactivation. All patients planned to be started on rituximab should be screened for hepatitis B surface antigen and total core antibody, with antiviral prophylaxis given depending on test results. In eculizumab treated patients, immunization against meningococcal serogroups ACWY and B is recommended. In addition, some guidelines suggest antibiotic prophylaxis for the duration of eculizumab treatment. In splenectomized patients, counseling and immunization are cornerstones of infection prevention. Several federal and society guidelines about immunizations and prophylactic antimicrobial therapies for patients treated with various immunosuppressive agents exist and are summarized in this manuscript in a clinical-focused table. In addition, management suggestions are made where no formal guidelines exist.

Cellular expression of CD markers in immune thrombocytopenic purpura: implications for prognosis

Immune thrombocytopenic purpura (ITP) is an autoimmune bleeding disorder associated with platelet destruction. Abnormalities in frequency and function of different immune cells can play a crucial role in this disease. The aim of this study was to evaluate the prognostic value of CD markers' expressions by immune cells in ITP. Peripheral blood samples were collected from 25 ITP patients before and after treatment. The expression of CD markers was evaluated by flow cytometry technique. The expression of CD38 and CD56 was significantly lower before treatment than after it (p = 0.025 and p = 0.036, respectively). Furthermore, a positive correlation was found between CD38 expression with platelet count before (r = 0.496, p = 0.012) and after treatment (r = 0.404, p = 0.045). No significant relationship was found between this marker and platelet count while CD4 expression was higher before treatment than after it (p = 0.002). In conclusion, CD38 may have independent prognostic value in ITP and we suggest that it can be a prognostic marker for this disease.

Efficacy and Safety of a New 10% Intravenous Immunoglobulin Product in Patients with Primary Immune Thrombocytopenia (ITP)

BACKGROUND

In the current study, we aimed to investigate the efficacy and safety of intravenous immunoglobulin (IVIg)-SN 10%, a new 10% IVIg formulation, in adult patients with severe primary immune thrombocytopenia (ITP; platelet count < 20 × 10⁹/L).

METHODS

Patients diagnosed as primary ITP, aged 19 years old or more, and had a platelet count of < 20 × 10⁹/L by screening complete blood cell count performed within 2 weeks of study commencement were eligible. Patients received IVIg-SN 10% at a dose of 1 g/kg/day for two consecutive days. Response was defined as the achievement of a platelet count of ≥ 50 × 10⁹/L at day 8.

RESULTS

Out of 81 eligible patients, 31 patients were newly diagnosed, 7 patients had persistent ITP, and 43 patients had chronic ITP. In intent-to-treat analysis, 61.3 patients (75.7%) achieved response and satisfied the pre-defined non-inferiority condition. Median time to response was 2 days and mean duration of maintaining response after the completion of IVIg therapy was 9.13 ± 8.40 days. Response rates were not found to be dependent on the phase of ITP or previous treatment for ITP. The drug was well tolerated and the frequency of mucocutaneous bleeding decreased during the study period.

CONCLUSION

In summary, IVIg-SN 10% formulation was found to be safe and effective in adult ITP patients (Trial registry at ClinicalTrials.gov, NCT02063789).