A rare presentation of immune thrombocytopenic purpura
Keywords:Pulmonary koch’s, Immune thrombocytopenic purpura, Megakaryocytes
Immune thrombocytopenic purpura (ITP) is defined as a hematologic disorder, characterized by isolated thrombocytopenia without any apparent cause. Some patients may be diagnosed during routine blood investigations or may present with bleeding diathesis. Treatment required for moderate to severe thrombocytopenia or those with bleeding manifestations. We present a case of 43 year old male, sputum positive pulmonary tuberculosis on isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E) (HRZE) with persistent thrombocytopenia. He developed hepatitis hence isoniazid (INH) and rifampicin were stopped. He had fever, rash, purpura, hematuria and blood tinged sputum with platelet count of 10,000. 4 random donor platelets (RDPs) given. He suffered from mild COVID-19 infection and recovered in 2 weeks but platelets remained low. Bone marrow examination was suggestive of ITP. Inspite of steroid therapy no improvement was seen. Later was treated with injection romiplostim, and started on systemic lupus erythematosus (SLE) regimen for tuberculosis and discharged with regular follow up. Last platelet count being 1,20000/dl, liver function tests normal and now restarted on HRZE.
Cines DB, Bussel JB. How I treat idiopathic thrombocytopenic purpura (ITP). Blood. 2005;106:2244-51.
Konkle BA. Immune thrombocytopenic purpura, Disorders of platelets and vessel wall. Harrison’s principle of internal medicine. McGraw Hill. 2014;111:825-7.
Kuwana M, Okazaki Y, Satoh T, Asahi A, Kajihara M, Ikeda Y. Initial laboratory findings useful for predicting the diagnosis of idiopathic thrombocytopenic purpura. Am J Med. 2005;118:1026-33.
Braselmann S, Taylor V, Zhao H. R406, an orally available spleen tyrosine kinase inhibitor blocks Fc receptor signaling and reduces immune complex-mediated inflammation. J Pharmacol Exp Ther. 2006;319(3):998-1008.
Roll P, Palanichamy A, Kneitz C. Regeneration of B cell subsets after transient B cell depletion using anti-CD20 antibodies in rheumatoid arthritis. Arthritis Rheum. 2006;54(8):2377-86.
Kuter DJ. New thrombopoietic growth factors. Clin Lymphoma Myeloma. 2009;9:347-56.
Kuter DJ, Bussel JB, Lyons RM, Pullarkat V, Gernsheimer TB, Senecal FM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008;371(9610):395-403.
Kuter DJ, Rummel M, Boccia R, Macik BG, Pabinger I, Selleslag D, et al. Romiplostim or standard of care in patients with immune thrombocytopenia. N Engl J Med. 2010;363:1889-99.
Cines DB, Gernsheimer T, Wasser J, Godeau B, Provan D, Lyons R, et al. Integrated analysis of long-term safety in patients with chronic immune thrombocytopaenia (ITP) treated with the thrombopoietin (TPO) receptor agonist romiplostim. Int J Hematol. 2015;102:259-70.
Payandeh M, Karami A, Karami N, Masgareh JB. Romiplostim: Successful treatment of a pregnant woman with refractory immune thrombocytopenia. Biomed Res Therap. 2018;5(8):2565-71.
Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;3:3829-66.
Tremblay G, Dolph M, Bhor M, Said Q, Roy A, Elliott B, et al. Cost-consequence model comparing eltrombopag and romiplostim in pediatric patients with chronic immune thrombocytopenia. Clinicoecon Outcomes Res. 2018;10:715-21.
Broome CM, Röth A, Kuter DJ, Scully M, Smith R, Wang J, et al. Inhibition of the classical pathway of complement with sutimlimab in chronic immune thrombocytopenic purpura patients without adequate response to two or more prior therapies. Blood. 2019;134(1):898.
Liu S, Shan N. DNA methylation plays an important role in immune thrombocytopenia. Int Immunopharmacol. 2020;83:106390.
Pietras NM, Pearson-Shaver AL. Immune Thrombocytopenic Purpura. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021;32965953.