Course Of Immune Thrombocytopenic Purpura Research Articles

Cell Death Markers in Children with Immune Thrombocytopenic Purpura: A Preliminary Study

Immune thrombocytopenic purpura (ITP) is an autoimmune disease with possible dysregulation of the apoptotic pathways. We aimed to evaluate the possible role of some apoptotic markers (caspase 3, caspase 8 and BCL2) in the pathogenesis and course of ITP. We investigated some apoptotic markers (caspase 3, caspase 8 and BCL2) using the flow cytometry in 60 children with newly diagnosed ITP, 20 children with chemotherapy-related thrombocytopenia (CRT) and 20 healthy children. We also assessed the effects of intravenous immunoglobulin (IVIG) and methyl prednisolone therapies on the platelet apoptosis in children with newly diagnosed ITP. We demonstrated significantly higher values of caspase 3 in the newly diagnosed ITP group than control and CRT groups, and non-significantly higher values of caspase 8 in the ITP group than the healthy group. After IVIG treatment, the platelet count increased in all patients, and there was a significant decrease in caspase 3 and caspase 8 levels while BCL2 level increased. Regarding methylprednisolone treatment, there was a significant decrease in BCL2 and caspase 8 levels while caspase 3 levels did not significantly decrease. There is a possible role of the caspase dependent cell death pathway of the platelets in the occurrence of newly diagnosed ITP. There is heterogeneity in the apoptotic changes of newly diagnosed ITP children who received IVIG versus those who received methylprednisolone.

Reduced IL-35 in patients with immune thrombocytopenia.

: The occurrence and development of primary immune thrombocytopenia is closely related to autoimmune imbalanced. Thus, we conducted the current study to investigate the modulation of IL-35, a newly identified immunological self-tolerance factor on immune thrombocytopenic purpura (ITP). We were enrolled peripheral blood in 21 adult healthy volunteers, 21 active primary ITP patients and 16 ITP patients in remission. In the same period, bone marrow plasma was drawn from active primary ITP patients and 16 bone marrow donors. Enzyme-linked immunoassay was used to measure IL-35 levels in bone marrow mononuclear cells and peripheral blood mononuclear cells. Real-time quantitative PCR was used to study the mRNA expression levels of p35, Epstein-Barr virus-induced gene 3 in bone marrow mononuclear cells and peripheral blood mononuclear cells. Compared with the normal group, IL-35 levels of in ITP patients were decreased significantly. IL-35 level in bone marrow plasma was decreased more significantly than that in peripheral blood plasma at the same stage. The results showed that plasma IL-35 levels were significantly decreased in patients with active ITP compared with those of control individuals, and IL-35 levels in bone marrow plasma were decreased more significantly compared with those at the same stage. The pathogenesis of ITP is associated with decreased IL-35 levels. Further studies are needed to expand sample content and explore more in-depth investigate a possible role of IL-35 in the pathogenesis and course of ITP.

Quantification of specific T and B cells immunological markers in children with chronic and transient ITP.

Immune thrombocytopenic purpura (ITP) is characterized by a transient (nonchronic) or permanent (chronic) decline in the number of platelets. Predicting the course of ITP, at the time of diagnosis, is of importance. Here we studied at diagnosis, clinical and immunological parameters in order to distinguish between different courses. The latter included the measure of new B and T cells using quantification of kappa-deleting recombination excision circles (KRECs) and T-cell receptor excision circles (TRECs), respectively. Blood samples were collected from 44 children with a clinical diagnosis of ITP. Real-time PCR was performed in order to quantify the number of copies of TREC and KREC followed by collection of clinical data from medical files. The children were retrospectively divided into two groups: chronic and nonchronic. Twenty-four patients (54%) were classified as nonchronic ITP and 20 patients (46%) were classified as chronic ITP. We confirmed some clinical parameters (e.g., gender, age) but not others (e.g., preceding infection, level of thrombocytopenia) that distinguish patients with chronic and nonchronic course. While KREC quantification was similar in patients regardless the outcome of their disease, it was significantly higher than the level of controls (P < 0.05). TREC quantification was not different between patients and controls. KREC but not TREC levels are different in patients comparing to controls, pointing to an overreaction of B-cell development as a role in the pathogenesis of ITP. These results may shed more lights on the immune mechanism of ITP.

Second Generation Direct-Acting Antiviral Agents Eradicate Hepatitis C Virus (HCV) but Exacerbate Thrombocytopenia in a Patient with HCV-Associated Immune Thrombocytopenic Purpura (ITP): Case Report

BackgroundLymphotropism of HCV induces chronic immune stimulation, facilitating production of wide variety of autoantibodies, leading to HCV driven autoimmunity. Immune thrombocytopenic purpura (ITP) is one of extra hepatic manifestations of autoimmune diseases in HCV infection.The treatment landscape of hepatitis C virus infection has been dramatically altered in 2013 with the approvals of the second-generation protease inhibitor simeprevir and the nucleotide polymerase inhibitor sofosbuvir. In most patients treated with the direct-acting antiviral agent (DAA), HCV RNA became undetectable.However a little is known about how DAA therapy affects autoimmune diseases associated with HCV, especially in ITP. Cessation of immune stimulation by HCV following the treatment may alter immune responses and may modify autoimmune diseases.We report here a case of acute exacerbation of ITP following DAA treatment. DAA therapy appears to precipitate acute exacerbation of thrombocytopenia and ITP became refractory to all treatments including the measures that used to induce remission prior to DAA treatment.Case reportA 67-year-old man was diagnosed chronic HCV infection, genotype 1b, in 1997. He failed treatment with Interferons. Chronic active hepatitis subsequently progressed into cirrhosis with portal hypertension. His ITP required frequent treatments with Prednisone and IVIG. It became severe in early 2013. His platelet counts were low at 10,000. He responded well to high dose Prednisone but could not continue because of worsening diabetes. He also failed Rituxan. He received multiple treatments including eltrombopag and romiplostin which he did not respond well to. His ITP finally stabilized with monthly infusion of WinRho as maintenance therapy with platelet counts hovering around 40.000 for 6 months.In March 2014, he was started on HCV treatment with simeprevir, sofosbuvir and ribavirin. His baseline platelet count prior to the new treatment was in the 50000’s. It plummeted to below 10.000 two weeks into treatment. He developed multiple ecchymosis and blood blisters in the mouth. He completed his HCV treatment on June 3, 2014. His viral load was no longer detectable.However, ITP remained refractory and severe with platelet counts around 10,000. High dose Prednisone or WinRho which had been effective in raising platelet counts previously were no longer effective after DAA therapy. During this acute exacerbation of ITP, he was treated with IVIG 3 times a week and low dose Prednisone and NPlate weekly with increasing dosage. He developed frequent blood blisters in mouth and gum bleeding requiring emergency room visits and hospitalization where he received platelet transfusions along with IVIGG and high dose Prednisone. His hemoglobin was stable throughout. IVIGG was reduced to 2 times a week. At 8 weeks following completion of DAAs, his platelet count improved to 40.000s range without clinical sign of bleeding.DiscussionIt has been shown that the frequency of B-cell production of anti- GPIIb-IIIa antibody, an antibody against the major platelet surface autoantigen (BP IIb-IIIa) recognized by anti-platelet antibodies in patients with idiopathic thrombocytopenic purpura (ITP), was greater in HCV-ITP (9). An inverse correlation was found between platelet count and B-cell anti–GPIIb-IIIa Ab production in 51 patients with liver cirrhosis (73% with hepatitis C).In our patient, ITP was stable with maintenance infusion of WinRho for 6 months. Acute exacerbation of ITP 2 weeks into DAA therapy suggests that it was triggered by the DAAs. Thrombocytopenia is a well-recognized complication of interferon therapy for treatment of viral hepatitis. Simeprevir and sofosbuvir however, are not well known to affect the platelet count.A little is known on effect of DAAs on thrombocytopenia. Immune alteration following eradication of HCV and subsequent modification of autoimmunity could affect course of ITP associated with HCV infection. Meanwhile, it is important for physicians and patients to be aware of potentially dangerous complications of these second generation DAAs. DisclosuresNo relevant conflicts of interest to declare.

Clinical significance of serum cytokine levels and thrombopoietic markers in childhood idiopathic thrombocytopenic purpura.

Biological markers useful for defining children with newly diagnosed immune thrombocytopenic purpura (ITP) who are likely to develop the chronic form of the disease are partially lacking. The purpose of this study was to assess the clinical role of both immunological and thrombopoietic markers in children with ITP and correlate their levels with different disease stages. We enrolled 28 children with ITP at the onset of their disease, who were followed-up for a whole year and divided according to whether their disease resolved within the 12 months (n=13) or became chronic (n=15), 11 subjects with chronic ITP off therapy for at least 1 month at the time of enrolment, and 30 healthy matched controls. Serum levels of T helper type 1 and 2 and T regulatory-associated cytokines, such as interferon γ, tumour necrosis factor α, interleukin (IL) 2, IL6, IL10, and thrombopoietin were measured in all children using quantitative immunoenzymatic assays, while reticulated platelets were evaluated by flow cytometric analysis. Serum IL10 levels were significantly higher in patients with an acute evolution of ITP than in either healthy controls (p<0.001) or patients with chronic progression of ITP (p<0.05). Reticulated platelet count and thrombopoietin levels were significantly higher in ITP patients at the onset of their disease, whether with acute resolution or chronic progression, than in healthy subjects (p<0.01; p<0.001), but did not differ between the groups of patients. IL-10 seems to predict the clinical course of ITP, as it is significantly higher at the onset of disease in patients who obtain disease remission in less than 1 year.

Study of Polymorphisms in DNMT3B promoter and IL-1 Ra in Childhood Idiopathic Thrombocytopenic Purpura.

AbstractAbstract 3705Idiopathic thrombocytopenic purpura (ITP) or primary immune thrombocytopenia is one of the most common blood diseases as well as the commonest acquired bleeding disorder in childhood. Although the etiology of ITP is unclear, in the pathogenesis of the disease both environmental and genetic factors including polymorphisms of TNF-a, IL-10 and IL-4 genes have been suggested to be involved. Aim: To investigate the association of the single-nucleotide polymorphism (SNP) in DNA methyltransferase 3B (DNMT3B C46359T) gene promoter and the polymorphism of IL-1 receptor antagonist (IL-1 Ra) intron-2 with the risk of immune thrombocytopenic purpura in childhood. Methods-patients: The genomic DNA of bone marrow mononuclear cells (MNC) of 20 children with idiopathic thrombocytopenic purpura, and peripheral blood leykocytes of 20 healthy children and 40 healthy adult volunteers (blood donors), was isolated and the region of interest was amplified by PCR. Furthermore for the DNMT3B polymorphism following digestion with Avr II the products were analyzed on agarous gel. Results: The frequencies of DΝMT3B C/C, C/T, T/T genotypes and C and T alleles in children with ITP were 50%, 35%, 15%, 67.5% και 32.5%, respectively. No significant differences were found in genotype and allele distribution between children with ITP and healthy children or adults (p=0.778 and p=1, respectively). However, there was significant difference in genotypic distribution of IL-1 Ra among children with ITP and control groups: children (p=0.001) and adults (p=0.005) as well as in allelic frequencies of IL-1 Ra between the same groups (p=0.000 and p=0.005 respectively). More specifically, children with Ι/Ι genotype or I allele seem to have decreased risk of development of ITP (OR: 0.07 [0.01–0.4]) compared both to their healthy counterparts and to healthy adults (OR: 0.17 [0.05–0.54]). Moreover the presence of the I/II genotype seems to increase 8.56 times the relative risk for disease development (OR: 8.56 [2.36–30]) while the presence of the II allele 3.8 times (OR: 3.8 [1.45–9.9]). Conclusion: The SNP (C46359T) in the promoter of DNMT3B does not seem to correlate with the diagnosis of ITP whilst the polymorphism of IL-1 receptor antagonist (IL-1 Ra) intron-2 seems to have an association with the development of the disease. This finding has to be further investigated in order its role in the pathogenesis and course of immune thrombocytopenic purpura to be confirmed. Disclosures:No relevant conflicts of interest to declare.

Prevalence and clinical characteristics of immune thrombocytopenic purpura in a cohort of monoclonal gammopathy of uncertain significance

Monoclonal gammopathy of uncertain significance (MGUS) may become symptomatic for autoimmune manifestations. We report on the prevalence and clinical course of immune thrombocytopenic purpura (ITP) observed in a consecutive series of 228 MGUS patients. At MGUS diagnosis, ITP was determined in 6/228 cases, accounting for a prevalence of 2630/100 000 [95% confidence interval (CI): 1210-5620]. One incidental ITP case occurred after 21 months of follow-up. After a follow-up of 681.3 patient-years, the crude incidence of ITP in MGUS was 146.8 per 100 000 patient-year (95% CI: 3.7-817.8). Overall, these observations point to an association between MGUS and ITP.

A case report of POEMS syndrome developing during the clinical course of immune thrombocytopenic purpura

Immune thrombocytopenia is commonly seen in patients with lymphoproliferative disorders, but is rare in patients with multiple myeloma. POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) is defined by the presence of a peripheral neuropathy, a monoclonal plasma cell disorder, and at least one of the following: endocrinopathy, skin changes, osteosclerotic myeloma, Castleman's disease, organomegaly, edema, or papilledema. In this paper, we present a patient with immune thrombocytopenic purpura (ITP) who developed POEMS syndrome during the clinical course of his ITP, and report on the early appearance of an isolated paraneoplastic symptom before the other diagnostic components of POEMS syndrome had developed. To our knowledge, this is the first description of coexistent ITP and POEMS syndrome in the literature.

The Effect of Tumor Necrosis Factor (TNFα) Inhibition on Platelet Counts in Adults and Children with Persistent ITP.

Immune Thrombocytopenic Purpura (ITP) is hematologic disorder caused by autoimmune opsonization and premature destruction of platelets. Approximately 20% of children and the majority of adults will have a chronic course of ITP with antibody-mediated destruction of platelets and the inability to clear immune complexes. Pro-inflammatory cytokines IL-2, TNF-α and IFN-γ are secreted following a Th1 response and are elevated in patients with chronic ITP. Recent treatments for chronic ITP in adults and children have focused on quelling dysregulated T and B lymphocyte activity. We conducted a pilot clinical trial of etanercept, a fusion peptibody composed of the soluble TNF-α receptor and the Fc portion of Ig. Hematologic and immunologic responses were measured before, during (blood counts only) and after a 12-week regimen of 0.4mg/kg/dose (max dose 25 mg) of subcutaneous etanercept, given twice weekly. Only fixed-dose prednisone or danazol were allowed as concomitant ITP medications. Cytokine concentrations were measured pre- and post-treatment from plasma and cultured lymphocytes (unstimulated or PHA- [2.5ng/ml] stimulated). Sixteen patients (9 male, 7 female), with chronic ITP (8 post-splenectomy) an initial platelet concentration < 30 × 109/L were enrolled with data evaluable for 15. The mean age of the patients was 31 years (median 32, min/max 7/52 years). One patient withdrew due to dizziness thought related to the study drug. One patient developed autoimmune hemolytic anemia, was diagnosed with Evans syndrome at treatment week 3 and withdrew from the study. Otherwise, no severe or serious related adverse events were observed. Two patients had a complete platelet response (CR, plt count > 150 × 109/L at least 6 weeks post treatment), 6 had a partial response (PR, plt count > 30 × 109/L and double baseline plt count), one had a minimal response (MR, plt count > 30 × 109/L) and 5 had no platelet response (NR). Two of the patients with PR had a platelet count rise that lasted at least until the end of the 8 week post-treatment observation period. The platelet response rate in nonsplenectomized and splenectomized patients was 67% and 28%, respectively, p = 0.1. Concentrations of IL-1β, IL-4, IL-6, IL-10 IFN-γ and TGF-β, before and at the end of the 12-week treatment course, showed marked inter-patient variation and did not predict the platelet count outcome. Both patients that had a CR had a reduction in PHA-stimulated TNF-α of 33 and 30%, respectively. Others with NR to treatment had similar declines in TNF-α, however. Although the precise mechanism of action is unclear, etanercept treatment led to at least a partial platelet response in 50% of patients with persistent ITP and was well-tolerated.

The clinical course of immune thrombocytopenic purpura in children who did not receive intravenous immunoglobulins or sustained prednisone treatment

Objective: To demonstrate the result of watchful waiting without specific therapy in unselected children with acute immune thrombocytopenic purpura (ITP). Study design: Between May 1992 and October 1999, 55 consecutive children (aged 2 months to 16 years; 28 boys and 27 girls) with acute ITP did not receive intravenously administered immune globulin G (IVIG) or sustained prednisone treatment. Patients with extensive mucosal bleeding were given prednisone, 2 mg/kg/d, for 3 days. Results: In 37 of 55 patients the initial platelet count was <10,000/μL. Ten of these patients had active mucosal bleeding. Five additional patients with bleeding had platelet counts between 10,000 and 20,000/μL. Four patients were given a 3-day course of prednisone. Chronic ITP occurred in 7 (13%) of the patients; 29 patients achieved remission within 6 weeks, and 19 patients, between 6 weeks and 6 months. No life-threatening bleeding occurred, and no patient died. Conclusion: Most children with severe thrombocytopenia do not have active mucosal bleeding. This management approach, which did not administer specific therapy, avoided side effects, reduced cost, and was effective. (J Pediatr 2000;137:629-32)

Chronic immune thrombocytopenic purpura in childhood.

Immune thrombocytopenic purpura (ITP) is a bleeding disorder and is traditionally divided in acute and chronic forms based on the duration of the disease. Chronic ITP is characterized by a persistence of thrombocytopenia for more than 6 months. Ten to 20% of children with ITP and almost all adults will develop the chronic condition. Pathophysiology of chronic ITP suggests an autoimmune process and a dysregulated immune response. There are no risk factors to predict the clinical course of ITP. Controlled clinical trials are needed to clarify many diagnostic and therapeutic aspects of chronic ITP, as recently stated by a panel of pediatric and adult hematologists on behalf of The American Society of Hematology (ASH). In this article, we will focus on pathophysiological, diagnostic, and management aspects of chronic childhood ITP.

Platelet autoantigens: identification and characterization using immunoblotting.

Antiplatelet autoantibodies are important in the etiology of idiopathic (or immune) thrombocytopenic purpura (ITP). Studies using immunoblotting techniques have been helpful in identifying the antigenic target proteins for the antibodies. Antibodies against the glycoprotein (GP) IIIa portion of the GPIIb/IIIa complex were the first to be demonstrated by this approach. Similar GPIIIa autoantigens have also been found to be the most frequent targets of ITP antibodies. Not all anti-GPIIIa antibodies are directed against the same epitope on GPIIIa. A subset of anti-GPIIIa antibodies found in patients with an acquired qualitative platelet dysfunction actually interfere with fibrinogen binding to normal platelets. Antibodies directed against targets on GPV have been found in patients with acute ITP of childhood. In patients with ITP associated with lupus erythematosus, antibodies which bind to intracellular proteins of apparent molecular weights of 66 and 108 kDa have been detected. Thus, ITP antibodies can have a variety of target antigens. Study of larger series of patients will determine whether identification of platelet autoantigens correlates with clinical course of ITP.

Effect of danazol in immune thrombocytopenic purpura.

Danazol and vinblastine are effective in many patients with chronic immune thrombocytopenic purpura (ITP). To evaluate the mechanism of action of these drugs, we studied six consecutive patients with chronic ITP treated with danazol and one treated with vinblastine. All the patients responded clinically without a notable change in the level of platelet-associated IgG. Instead, the clinical response to therapy was associated with a decrease in the number of monocyte binding sites for monomeric IgG (Fc receptors). In one patient, clinical relapse was associated with a spontaneous 2.7-fold increase in the number of monocyte Fc (IgG) receptors, without a change in the level of platelet-associated immunoglobulin. A decrease in the number of monocyte Fc (IgG) receptors following vinblastine infusion was associated with a clinical remission. We conclude that the clinical course of ITP may be influenced by the expression of monocyte or macrophage Fc (IgG) receptors. Danazol and vinblastine may mediate their clinical effect, at least in part, by influencing the number of available Fc (IgG) receptors on phagocytic cells.