[Step by step - A diagnostic approach to bleeding disorders]. / Abklärung erhöhter Blutungsneigung ­ Schritt für Schritt.

The main symptom of hemorrhagic diathesis is an increased bleeding tendency. Due to the subjectivity of various features of the bleeding history, unclarity of the family history, and an individualization of the extent of diagnostic the evaluation of a suspected bleeding disorder represents a challenging endeavour in hematology. Hemorrhagic diathesis can be divided into the following sub-categories: disorders in primary hemostasis (e. g. von Willebrand disease, different causes of thrombocytopenia), secondary hemostasis (e. g. hemophilia A and B, Vitamin K deficiency) and fibrinolysis, and in connective tissue or vascular formation. This article reviews available diagnostic methods for bleeding disorders, from structured patient history to highly specialized laboratory diagnosis.

Nivolumab-related severe thrombocytopenia in a patient with relapsed lung adenocarcinoma: a case report and review of the literature.

BACKGROUND: Immune checkpoint inhibitor therapy has changed the standard drug therapy for relapsed or advanced non-small cell lung cancer; its efficacy is well-recognized by pulmonary physicians, oncologists, and thoracic surgeons. Nivolumab, one of the anti-programmed cell death 1 antibodies, was the first immune checkpoint inhibitor to be approved and is used as a standard second-line regimen for patients with non-small cell lung cancer irrespective of the expression of programmed cell death ligand 1. Programmed cell death 1 antibodies have been generally confirmed to be less toxic than conventional cytotoxic chemotherapy, although unusual immune-related adverse events such as type I diabetes mellitus, adrenal failure, and myasthenia gravis may occur with a very low incidence. A case of severe grade V immune-related thrombocytopenia after two courses of nivolumab as second-line therapy for relapsed non-small cell lung cancer is reported. CASE PRESENTATION: An 82-year-old Japanese woman with relapsed lung adenocarcinoma was treated with nivolumab as second-line systemic therapy at our institute. Her laboratory data indicated thrombocytopenia suspected to be an immune-related adverse event following two courses of nivolumab. Subsequently, she developed a massive pulmonary hemorrhage and left cerebral infarction despite intensive treatment including systemic steroid therapy. Although there have been a few reports of thrombocytopenia caused by nivolumab, this is the first report of grade V thrombocytopenia following administration of nivolumab for relapsed non-small cell lung cancer. CONCLUSION: A very difficult case of grade V immune-related thrombocytopenia after the administration of nivolumab as second-line therapy for relapsed lung adenocarcinoma was described. Immune-related thrombocytopenia is a rare adverse event, but it must be considered a possible complication because it may become critical once it has occurred.

High-dose fotemustine in temozolomide-pretreated glioblastoma multiforme patients: A phase I/II trial.

BACKGROUND: Glioblastoma multiforme (GBM) is a rare and deadly disease, with a reported average incidence rate of 3.19 cases per 100,000 inhabitants. Fotemustine, a third-generation nitrosourea with an alanine phosphor carrier that facilitates cellular penetration, has been extensively investigated in the setting of recurrent/progressive disease after initial treatment. Fotemustine is usually administered following a schedule consisting of 3 doses every week, followed by maintenance doses administered every 3 weeks. METHODS: In this phase I/II trial, we aimed to assess whether the use of a biweekly regimen allowed administration of higher dose than the standard 100 mg/m dose approved per label indication in a population of patients with recurrent GBM. In this phase I/II trial, fotemustine was administered intravenously over 1 hour every 2 weeks at either 120 or 140 mg/m doses for up to 1 year, until disease progression, unacceptable toxicity, or patient's request to withdraw from the study. The phase I part of the trial was conducted following the classic 3+3 study design. The phase II part of the trial was a single-arm study. The primary efficacy endpoint was the percentage of patients who had not progressed after 24 weeks (PFS-24). RESULTS: Thirty-seven patients were enrolled in this phase I/II trial from August 2006 to November 2011. Treatment was well tolerated in the overall population. Main severe toxicity was grades 3 and 4 thrombocytopenia, which occurred in 4 of 6 patients treated at the 140 mg/m dose level and in 3 of 31 patients treated at 120 mg/m. Median PFS and overall survival were 12.1 (1-40.2) weeks and 19.7 (1-102) weeks, respectively. CONCLUSION: We conclude that fotemustine can be safely administered at 120 mg/m biweekly. The efficacy of such modified schedule and doses should be compared to the biweekly schedule at 80 mg and the standard weekly schedule at 80 to 100 mg/m.

Mean platelet diameter measurements to classify inherited thrombocytopenias.

INTRODUCTION: Mean platelet volume (MPV) assists the differential diagnosis of inherited thrombocytopenia (IT) but lacks standardisation and varies between automated analysers. Classification of IT based on mean platelet diameter (MPD) has been proposed by an international collaborative study but has not been validated. METHODS: To assess the applicability of MPD to classify forms of IT, digital images of blood films from patients with established genetic causes for IT were generated, and the MPD measured (ZEISS Axio-scanner and Image J software) by a blinded reviewer. Comparison was made to the proposed classification system. RESULTS: Mean platelet volume was measured in thrombocytopenia with different genetic aetiologies, bilallelic BSS (bBSS) (n = 1), monoallelic BSS (mBSS) (n = 2), MYH9-related disorders (MYH9-RD) (n = 11), GFI1B-related thrombocytopenia (RT) (n = 15), FLI1-RT (n = 2), TUBB1-RT (n = 3), ITGA2B/ITGB3-RT (n = 1), RUNX1-RT (n = 2) and controls (n = 54). bBSS and 82% of MYH9-RD samples had MPD >4 µm which correlated with "IT with giant platelets." Only 55% of samples expected in the "large platelet group" had MPD meeting the classification cut-off (MPD >3.2 µm). FLI1-RT MPD were significantly larger than expected whilst ITGA2B/ITGB3-RT MPD were smaller than proposed. MPD in FPD/AML were "normal." CONCLUSION: Platelet MPD measurements are a useful guide to classify IT, but the time taken to record measurements may limit clinical applicability.

ASFA Category IV becomes Category I: Idiopathic thrombotic thrombocytopenic purpura in a patient with presumed gemcitabine-induced thrombotic microangiopathy.

In the implementation of American Society for Apheresis national guidelines, the decision for therapeutic plasma exchange may be confounded by a clinical presentation that fits both a Category I and IV designation. We report the case of a 45-year-old female who presented with concern for a Category IV disorder, gemcitabine-induced thrombotic microangiopathy, and was ultimately diagnosed with a Category I disorder, idiopathic thrombotic thrombocytopenic purpura. This case highlights the importance of ruling out idiopathic TTP by a thorough evaluation for ADAMTS13 activity and inhibitor, even when an alternate thrombotic microangiopathy diagnosis may be likely.

High prevalence of heparin induced thrombocytopenia with thrombosis among patients with essential thrombocytemia carrying V617F mutation.

Arterial and venous complications are major causes of morbidity and mortality in myeloproliferative neoplasms (MPNs). MPNs patients, frequently receive heparin. Heparin-induced thrombocytopenia (HIT) is a rare but potentially life-threatening complication resulting in a severe acquired thrombophilic condition. We carried out a retrospective analysis to evaluate occurrence of new thrombotic events during heparin therapy in essential thrombocythemia (ET) patients. We studied 108 ET patients on heparin for treatment of previous thrombotic events or in thromboprophilaxis. Fifty-eight of them carried JAK 2 V617F mutation while 50 patients were without V617F mutation. Ten patients, among those with JAK 2 V617F mutation after a median of 10 days from heparin treatment presented a platelet drop, new thrombotic events and in 10/10 cases heparin-related antibodies were found. In the other group, two patients (4%) presented a platelet drop, thrombotic manifestations and heparin related antibodies. Our data show that HIT is more frequent, during heparin treatment, in patients with ET carrying V617F mutation, as compared with patients without mutations (P = 0.029). ET with V617F mutation seems to be associated with higher risk of thrombotic complications during heparin treatment. Monitoring platelet counts very closely during the course of heparin is essential especially in ET patients in which platelet drop may be hidden by constitutional thrombocytosis.

Lysosomal storage disorders: Morphologic appraisal in Indian population.

BACKGROUND: Lysosomal storage disorders (LSDs) comprise a group of at least 50 distinct genetic diseases, each one resulting from the deficiency of a particular lysosomal enzyme involved in metabolism. We attempt to study and further subclassify pediatric LSDs into Gaucher's and non-Gaucher's category based on the morphologic variables seen in the bone marrow aspiration smears and trephine biopsy sections. MATERIALS AND METHODS: Pediatric (<12 years age) cases of LSDs diagnosed by bone marrow aspiration and trephine biopsy specimens, in the last 12 years period, were retrieved. The archival material and the relevant clinical as well as hematologic parameters were reviewed. RESULTS: From January 1997 to December 2008, 55 cases were diagnosed as LSDs. Based on bone marrow morphology, 56% (n = 31) cases were diagnosed as non-Gaucher's and the remaining 44% (n = 24) cases as Gaucher's disease, the ratio being 1.29:1. Anemia and thrombocytopenia were more commonly observed in Gaucher's disease (91.67 and 62.5%) as compared to non-Gaucher's group (74.19 and 19.35%). Neurologic symptoms and signs were more frequently present in non-Gaucher's cases (45.16%) as compared to Gaucher's group (29.17%). CONCLUSION: LSDs can be classified into Gaucher's and non-Gaucher's subtypes based on the characteristic cytomorphology of the storage cells in Giemsa-stained bone marrow aspiration smears and on hematoxylin and eosin-stained trephine biopsy sections. This approach would be fairly adequate for therapeutic and prognostic purposes in resource.constrained settings, where enzyme studies and mutational analysis may not be easily available.

Thrombocytopenia and craniotomy for tumor: A National Surgical Quality Improvement Program analysis.

BACKGROUND: To the authors' knowledge, the current study is the first national analysis of the association between preoperative platelet count and outcomes after craniotomy. METHODS: Patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry (2007-2014) and stratified by preoperative thrombocytopenia, defined as mild (125,000-149,000/µL), moderate (100,000-124,000/µL), severe (75,000-99,000/µL), or very severe (<75,000/µL). Cox proportional hazards analysis was used to evaluate the association between thrombocytopenia and 30-day mortality, and multivariable logistic regression with complications and unplanned reoperation. Covariates included patient age, sex, tumor histology, American Society of Anesthesiologists class, functional status, comorbidities, and surgical time. RESULTS: A total of 14,852 patients were included in the current study and thrombocytopenia was classified as mild in 4.4% (646 patients), moderate in 2.0% (290 patients), severe in 0.7% (105 patients), or very severe in 0.4% (66 patients) of patients. The adjusted hazard of 30-day death was significantly higher for patients with moderate (6.6%; hazard ratio [HR], 2.13 [95% confidence interval (95% CI), 1.30-3.49; P = 0.003]), severe (10.5%; HR, 2.33 [95% CI, 1.18-4.60; P = 0.02]), and very severe (10.6%; HR, 3.65 [95% CI, 1.71-7.82; P = 0.001]) thrombocytopenia, compared with patients without thrombocytopenia (2.9%), with an increased effect size noted with greater thrombocytopenia. Likewise, when the platelet count was evaluated continuously, a higher platelet count was associated with a lower hazard of 30-day mortality (HR, 0.987 [95% CI, 0.981-0.993; P<.001]), developing any complication (odds ratio, 0.985 [95% CI, 0.981-0.988; P<.001]), and reoperation (odds ratio, 0.990 [95% CI, 0.983-0.994; P = .003]). Unplanned reoperation was due to intracranial hemorrhage in 53.3% of patients with moderate thrombocytopenia. CONCLUSIONS: In this National Surgical Quality Improvement Program analysis, moderate and severe thrombocytopenia were associated with mortality and reoperation after craniotomy for tumor. Cancer 2016;122:1708-17. © 2016 American Cancer Society.

Thrombopoietin: a potential diagnostic indicator of immune thrombocytopenia in pregnancy.

To evaluate whether the serum thrombopoietin levels in pregnancy-associated immune thrombocytopenia (ITP) differ from those in gestational thrombocytopenia, and reveal the possibility of thrombopoietin serving as a marker for differential diagnosis. Serum thrombopoietin concentration was determined in ITP in pregnancy (n = 35), gestational thrombocytopenia (n = 31), healthy pregnancy (n = 32), age-matched nonpregnant ITP (n = 32) and nonpregnant healthy controls (n = 35) by ELISA. The serum thrombopoietin level of ITP in pregnancy (1283 ± 646 pg/mL) was significantly higher than gestational thrombocytopenia (187 ± 64 pg/mL) (P < 0.01), although the platelet counts of these two disorders may overlap. Twenty-nine of 35 patients with ITP in pregnancy had thrombopoietin values >500 pg/mL, whereas none of the gestational thrombocytopenia patients' thrombopoietin levels exceeded 500 pg/mL. In addition, ITP in pregnancy presented a markedly higher thrombopoietin level than nonpregnant ITP (88 ± 41 pg/mL) (P < 0.01), indicating that the pathogenesis of pregnant and nonpregnant ITP was different. Our findings suggest that measurement of serum thrombopoietin concentration provides valuable diagnostic information for differentiating ITP in pregnancy from gestational thrombocytopenia. Thrombopoietin represents a reliable marker for ITP in pregnancy.

Prospective diagnostic accuracy evaluation and clinical utilization of a modified assay for platelet-associated immunoglobulin in thrombocytopenic and nonthrombocytopenic dogs.

BACKGROUND: No diagnostic tests reliably distinguish primary immune-mediated thrombocytopenia (pIMT) from other causes of thrombocytopenia. OBJECTIVES: The purpose of the study was to evaluate diagnostic sensitivity and specificity using modified direct and indirect platelet-associated immunoglobulin (PAIg) assays and reticulated platelets (RP) by flow cytometry for the classification of thrombocytopenic dogs and differentiating pIMT. METHODS: Platelets were isolated from plasma samples of thrombocytopenic dogs and nonthrombocytopenic healthy and ill dogs. For direct PAIg, they were analyzed by flow cytometry after incubation with anti-human amylase fluorescein isothiocyanate (FITC, negative control), anti-canine IgG-FITC, anti-canine IgM-FITC, and anti-human CD61-conjugated fluorochrome (AF647). For indirect PAIg, platelets from normothrombocytic dogs were incubated with thrombocytopenic dog plasma and analyzed similar to direct PAIg. RP percentages were determined based on forward light scatter vs thiazole orange fluorescence. RESULTS: Seventy-five thrombocytopenic dogs, 16 nonthrombocytopenic ill dogs, and 24 healthy dogs were evaluated. Diagnostic sensitivity and specificity utilizing direct IgG was 29.4% and 75.9%, respectively; when combining direct/indirect assays (IgG/IgM), it was 76.5% and 65.5%, respectively, for distinguishing pIMT. For RP, no significant difference between pIMT and sIMT was noted. RP > 8% with positive PAIg had a sensitivity of 94% and specificity of 27.6% for distinguishing pIMT. There was a significant difference in platelet concentration and CD61% staining between control and pIMT. CONCLUSIONS: The combined modified assays resulted in fair diagnostic sensitivity and specificity for the diagnosis of pIMT. The modification of the immunoglobulin assays improved diagnostic accuracy; however, a single panel to accurately classify thrombocytopenia remains elusive.

Platelet diameters in inherited thrombocytopenias: analysis of 376 patients with all known disorders.

Abnormalities of platelet size are one of the distinguishing features of inherited thrombocytopenias (ITs), and evaluation of blood films is recommended as an essential step for differential diagnosis of these disorders. Nevertheless, what we presently know about this subject is derived mainly from anecdotal evidence. To improve knowledge in this field, we evaluated platelet size on blood films obtained from 376 patients with all 19 forms of IT identified so far and found that these conditions differ not only in mean platelet diameter, but also in platelet diameter distribution width and the percentage of platelets with increased or reduced diameters. On the basis of these findings, we propose a new classification of ITs according to platelet size. It distinguishes forms with giant platelets, with large platelets, with normal or slightly increased platelet size, and with normal or slightly decreased platelet size. We also measured platelet diameters in 87 patients with immune thrombocytopenia and identified cutoff values for mean platelet diameter and the percentage of platelets with increased or reduced size that have good diagnostic accuracy in differentiating ITs with giant platelets and with normal or slightly decreased platelet size from immune thrombocytopenia and all other forms of IT.

Commentary on session: Immune thrombocytopenia nomenclature, guidelines, and natural history.

Two presentations discussed different aspects of immune thrombocytopenia (ITP) management. The first considered active monitoring for occult hemorrhage in the gastrointestinal tract, urinary tract, and brain. Participants generally did not feel that these would be useful in determining management of children with ITP since serious bleeding was likely to manifest itself. A single historical paper had suggested that microscopic cranial bleeding may result in chronic brain disturbance, but overall experience of ITP does not support this. Participants considered ways of studying this possibility but noted the considerable difficulties in setting up a formal study and suggested that the established registries should be alerted to capture long-term data on school performance. The second presentation focused on the extent to which recent papers are using the new terminology and guidelines. Participants noted the two new guidelines gave discrepant advice with regard to splenectomy. Management of ITP is not necessarily straightforward and needs to be tailored to the individual.

Immune thrombocytopenia nomenclature, consensus reports, and guidelines: what are the consequences for daily practice and clinical research?

New insights into the pathophysiology and the natural history of immune thrombocytopenia (ITP) and new therapeutical approaches have emerged in the last 10 years that have made necessary the update of previous guidelines. An important step towards the harmonization on both the definition of the disease and the phases of the disease, the objectives of treatment, and the criteria of response to be used in clinical trials has been first made possible throughout the International Working group on ITP. This important step has been followed by an international consensus report and the updated American Society of Hematology (ASH) guidelines focused on the investigation and management of ITP taking into account the data from the most recent clinical trials in the field. In this article, the consequences and translation that these guidelines may have or not on daily practice and on future clinical trials are discussed and the few controversies are pointed out. Whereas these guidelines are helpful for the investigation of ITP and for the harmonization of clinical trials, some area of uncertainties do remain for the best management of ITP and especially the choice of the best second-line strategy in persistent ITP is still far from being consensual.

Drug-induced immune thrombocytopenia.

Thrombocytopenia is caused by immune reactions elicited by diverse drugs in clinical practice. The activity of the drug-dependent antibodies produces a marked decrease in blood platelets and a risk of serious bleeding. Understanding of the cellular mechanisms that drive drug-induced thrombocytopenia has advanced recently but there is still a need for improved laboratory tests and treatment options. This article provides an overview of the different types of drug-induced thrombocytopenia, discusses potential pathologic mechanisms, and considers diagnostic methods and treatment options.

[Reticulated platelet count used for differentiation of the type of thrombocytopenia in pregnant women]. / Przydatnosc badania retykuloplytek w róznicowaniu maloplytkowosci wystepujacej u kobiet ciezarnych.

BACKGROUND: Analysis of reticulated platelets (RP), the youngest form of platelets in peripheral blood, is useful for assessment of thrombopoietic response in thrombocytopenic conditions due to intense immunological platelet destruction. AIM: The aim of the study was to assess the value of RP measurement for differentiation between pregnancy-related thrombocytopenia (PT), immunological thrombocytopenia (IM) and hereditary thrombocytopenia (HT) in pregnant women with platelet count below 100 G/L. MATERIAL: The study included 49 pregnant thrombocytopenia women (21 with PT, 22 with IM, 6 with HR) as well as 22 healthy pregnant women (Control). METHODS: The percentage of RP in peripheral blood was measured using double staining with: PE-labeled anti CD41 (Dako) and thiazole orange (Beckton Dickinson). The measurements were performed several times during pregnancy (II and III trimester) and delivery. Anti-platelet antibodies were tested by immunofluorescence and immunoensimatic assays. HPA1a antigen was determined by PCR/SSP. RESULTS: The average platelet count in all groups of thrombocytopenia women was significantly lower than in control group. The mean RP percentage in the control group (5.31%) was within the range of the haematological normal value (0.5-6%), and for thrombocytopenia women it was: 9.19% for PT women, 14.75% for IM women and 14.94% for HT women and was significantly higher than that in the control group. In the group of IM pregnant women the RP percentage was significantly higher in the II trimester than in the PT women. Anti-platelet antibody and HPA1a antigen testing excluded alloimmunological/fetus/neonatal thrombocytopenia in the study material. CONCLUSION: RP analysis has been proved useful for preliminary differentiation of PT and IT in the II trimester of pregnancy. Higher RP percentage informs the physician of the likelihood of immunological thrombocytopenia in the pregnant woman as well as of the delivery of a thrombocytopenia child.

Two consecutive open heart operations in a small child with heparin-induced thrombocytopenia type II using anticoagulation with heparin and tirofiban.

We report the use of the platelet glycoprotein IIb/IIIa antagonist tirofiban for cardiac surgery in a small child with active heparin-induced thrombocytopenia type II, including description of the postoperative course.

[Dabigatran as a therapeutic possibility in heparin-induced thrombocytopenia type II]. / Dabigatran como posibilidad terapéutica en el síndrome de trombocitopenia inducida por heparina tipo II.

The syndrome of heparin-induced thrombocytopenia (HIT), with an incidence of 0.2-0.5% in patients exposed to heparin for more than 4 days, is produced by an immune alteration with the formation of antibodies against the heparin platelet factor 4 complex. It presents a wide spectrum of clinical manifestations, the most frequent of which are thrombocytopenia, thrombotic arterial-venous phenomena, and cutaneous necrosis. Up to the present, lepiridin, recently suspended, and argatroban (direct thrombin inhibitors) have been the approved medicines normally used in treatment, administered in parenteral form. Dabigatran, a new anticoagulant medicine that is a direct and reversible thrombin inhibitor, could theoretically be a medicine employed in treating HIT. According to the bibliography consulted we are presenting the first case of HIT treated with dabigatran in the medical literature.

Thrombocytopenia resulting from mutations in filamin A can be expressed as an isolated syndrome.

Filaminopathies A caused by mutations in the X-linked FLNA gene are responsible for a wide spectrum of rare diseases including 2 main phenotypes, the X-linked dominant form of periventricular nodular heterotopia (FLNA-PVNH) and the otopalatodigital syndrome spectrum of disorders. In platelets, filamin A (FLNa) tethers the principal receptors ensuring the platelet-vessel wall interaction, glycoprotein Ibα and integrin αIIbß3, to the underlying cytoskeleton. Hemorrhage, coagulopathy, and thrombocytopenia are mentioned in several reports on patients with FLNA-PVNH. Abnormal platelet morphology in 2 patients with FLNA-PVNH prompted us to examine a third patient with similar platelet morphology previously diagnosed with immunologic thrombocytopenic purpura. Her enlarged platelets showed signs of FLNa degradation in Western blotting, and a heterozygous missense mutation in FLNA was detected. An irregular distribution of FLNa within the total platelet population was shown by confocal microscopy for all 3 patients. In vitro megakaryocyte cultures showed an abnormal differentiation, including an irregular distribution of FLNa with a frayed aspect, the presence of enlarged α-granules, and an abnormal fragmentation of the cytoplasm. Mutations in FLNA may represent an unrecognized cause of macrothrombocytopenia with an altered platelet production and a modified platelet-vessel wall interaction.