Reversal of Idiopathic Thrombocytopenic Purpura [ITP] with Fecal Microbiota Transplantation [FMT

Abstract

Purpose: Regarded as an autoimmune disorder, Idiopathic Thrombocytopenic Purpura is characterized by persistent fluctuating thrombocytopenia of unknown cause resulting in platelet destruction. Current treatments include corticosteroids, and other immunosuppressive medications, or splenectomy. The risk of serious morbidity/mortality is substantial, with life-threatening hemorrhagic events and death estimated at being 60 percent above expected mortality rate1. We report an unexpected finding in a patient with long-standing ulcerative colitis (UC) and ITP in whom FMT for UC resulted in a ‘cure' of her concomitant ITP. This response suggests an underlying infection of the gut microbiota as a possible etiology in this disorder. Methods: Case: A 39 year old female presented for opinion and management of her chronic, relapsing UC, diagnosed in 1984. The patient also had concomitant idiopathic thrombocytopenic purpura since 1995. Due to difficult-to-control UC and frequent relapses the patient was offered FMT prior to colectomy. Prior to undergoing FMT in January 1999, the patient's mean platelet levels were consistently beneath the lower limit of normal (mean 96.18, range 62-133). In the months following FMT the patient experienced an abrupt rise in her platelet count with a mean of 127 (range 56-188) which then normalized upwards to lie consistently within the upper limits of the normal range (mean 190, range 153-259) from March 2004 where they remain today. The patient also experienced a marked reduction in UC symptoms, passing 2-3 semi-formed stools daily, without bleeding or urgency. Results: We believe this is the first case of immune-mediated ITP successfully reversed using FMT. Transient thrombocytopenia has been reported secondary to infections with Helicobacter pylori, Campylobacter jejuni, Yersinia enterocolitica and Mycobacterium tuberculosis, all absent in this patient. Success of FMT in this ‘autoimmune' condition, traditionally etiologically unrelated to the gastrointestinal tract, suggests this therapy may be beneficial in other socalled ‘autoimmune' conditions and prompts us to reconsider the mechanisms behind ‘autoimmune disorders'. Conclusion: Our finding that ITP can be reversed by FMT points to an underlying GI infective cause. The success of this procedure in this ‘autoimmune' condition highlights the potential of FMT in other diseases previously thought to be ‘autoimmune'.