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      The Reactivation of Immune Thrombocytopenic Purpura After SARS-CoV-2 Infection

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      Author(s): 1 , , 1 , 1
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: intravenous immunoglobulins (ivig), platelet count (plt), bleeding risk, sars-cov-2, viral itp

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          Abstract

          Immune thrombocytopenic purpura (ITP) is an autoimmune disease associated with bleeding symptoms and thrombocytopenia. It is diagnosed in patients with low platelet count after all the other causes of thrombocytopenia are ruled out. It can be presented as a primary condition, or it can be associated with other diseases. We report a case of ITP in a 65-year-old female with a one-day history of spontaneous bleeding gums, bruising, and petechiae all over her body. In further review of her history, it was noted that she had a history of ITP in remission and was recovering from a recent SARS-CoV-2 infection. We have excluded all the other causes of her thrombocytopenia, and we suspected that her viral illness would likely trigger this episode. Here, we report a case of ITP reactivation after SARS-CoV-2 infection.

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          Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group.

          Francesco Rodeghiero, Roberto Stasi, Terry Gernsheimer … (2009)
          Diagnosis and management of immune thrombocytopenic purpura (ITP) remain largely dependent on clinical expertise and observations more than on evidence derived from clinical trials of high scientific quality. One major obstacle to the implementation of such studies and in producing reliable meta-analyses of existing data is a lack of consensus on standardized critical definitions, outcome criteria, and terminology. Moreover, the demand for comparative clinical trials has dramatically increased since the introduction of new classes of therapeutic agents, such as thrombopoietin receptor agonists, and innovative treatment modalities, such as anti-CD 20 antibodies. To overcome the present heterogeneity, an International Working Group of recognized expert clinicians convened a 2-day structured meeting (the Vicenza Consensus Conference) to define standard terminology and definitions for primary ITP and its different phases and criteria for the grading of severity, and clinically meaningful outcomes and response. These consensus criteria and definitions could be used by investigational clinical trials or cohort studies. Adoption of these recommendations would serve to improve communication among investigators, to enhance comparability among clinical trials, to facilitate meta-analyses and development of therapeutic guidelines, and to provide a standardized framework for regulatory agencies.
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            American Society of Hematology 2019 guidelines for immune thrombocytopenia

            Cindy Neunert, Deirdra Terrell, Donald M Arnold … (2019)
            Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients. These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP. In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations. The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non–life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists. There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.
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              Imbalance of regulatory and cytotoxic SARS-CoV-2-reactive CD4 + T cells in COVID-19

              Benjamin Meckiff, Ciro Ramírez-Suástegui, Vicente Fajardo … (2020)
              The contribution of CD4+ T cells to protective or pathogenic immune responses to SARS-CoV-2 infection remains unknown. Here, we present single-cell transcriptomic analysis of >100,000 viral antigen-reactive CD4+ T cells from 40 COVID-19 patients. In hospitalized patients compared to non-hospitalized patients, we found increased proportions of cytotoxic follicular helper (TFH) cells and cytotoxic T helper cells (CD4-CTLs) responding to SARS-CoV-2, and reduced proportion of SARS-CoV-2-reactive regulatory T cells (TREG). Importantly, in hospitalized COVID-19 patients, a strong cytotoxic TFH response was observed early in the illness which correlated negatively with antibody levels to SARS-CoV-2 spike protein. Polyfunctional T helper (TH)1 and TH17 cell subsets were underrepresented in the repertoire of SARS-CoV-2-reactive CD4+ T cells compared to influenza-reactive CD4+ T cells. Together, our analyses provide insights into the gene expression patterns of SARS-CoV-2-reactive CD4+ T cells in distinct disease severities.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 7 September 2023
                Publication date (Electronic, collection): September 2023
                Volume: 15
                Issue: 9
                Electronic Location Identifier: e44873
                Affiliations
                [1 ] Internal Medicine, White River Health System, Batesville, USA
                Author notes
                Article
                DOI: 10.7759/cureus.44873
                PMC ID: 10484802
                PubMed ID: 37692177
                SO-VID: 78431090-f249-48b6-9282-7c5fb0d8c381
                Copyright © Copyright © 2023, Posa et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 7 September 2023
                Categories
                Subject: Internal Medicine
                Subject: Oncology
                Subject: Hematology

                Keywords: intravenous immunoglobulins (ivig),platelet count (plt),bleeding risk,sars-cov-2,viral itp
                Data availability:
                Keywords: intravenous immunoglobulins (ivig), platelet count (plt), bleeding risk, sars-cov-2, viral itp

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