Combination of high-dose dexamethasone and antiretroviral therapy rapidly improved and induced long-term remission of HIV-related thrombocytopenic purpura.

We present a case of HIV-related thrombocytopenic purpura (HIV-ITP) successfully treated with high-dose dexamethasone and antiretroviral therapy (ART). Although high-dose dexamethasone is regarded as the first-line therapy in adult patients with non-HIV ITP, there is limited information on treatment of HIV-ITP and long-term prednisone therapy is considered the standard therapy. High-dose dexamethasone is preferable to conventional long-term prednisone therapy, because of fewer side effects mainly due to shorter steroid use. The ART helps achieve long-term remission for HIV-ITP, although this therapy lacks an immediate effect. In our patient, administration of high-dose dexamethasone resulted in rapid rise in platelet count and ART maintained long-term remission of HIV-ITP. The combination therapy is potentially suitable strategy for the treatment of patients with HIV-ITP and severe thrombocytopenia or bleeding.

Cytomegalovirus-associated immune thrombocytopenic purpura after liver transplantation.

Immune thrombocytopenic purpura (ITP) is a rare complication after liver transplantation. Infection with cytomegalovirus (CMV) is a frequent complication of organ transplantation and may induce autoimmune diseases, such as ITP. We report a case of ITP after primary CMV infection in a 3-year-old boy recipient of living-related orthotopic liver transplantation (OLT). The ITP developed 2 years after OLT in this patient who had received tacrolimus as an immunosuppressive agent, with nadir platelet counts of 5000/mm(3) in 2 weeks. The patient was treated with two courses of intravenous gamma globulin (1 g/kg/day for 2 days) and subsequent oral prednisolone (1.3 mg/kg/day for 2 weeks). He recovered from thrombocytopenia 4 weeks later. An inadequate immunosuppression, as evident by the low serum tacrolimus level (5.8 ng/mL before the episode of ITP) in this patient, may allow the development of ITP after CMV infection.

Acute human parvovirus B-19 infection in hospitalized children: A serologic and molecular survey.

BACKGROUND: The extent and clinical manifestations of acute human parvovirus B19 (B19) infection were assessed in previously healthy hospitalized children admitted with clinical syndromes potentially associated the virus. PATIENTS AND METHODS: The study was prospective and was conducted between October 2002 and August 2004 in the pediatric departments of 3 hospitals in Israel. The survey included previously healthy children who were hospitalized with 1 or more of the following acute diseases: acute nonallergic exanthema, fever for >1 week, aplastic anemia or pancytopenia, acute nonbacterial arthropathy, immune thrombocytopenic purpura (ITP), Henoch-Schönlein purpura (HSP) and aseptic meningitis. A control group of children with a proven, non-B19 infection was also studied. Serum samples obtained from each child on admission were tested for B19 DNA by real-time PCR and B19 IgM by ELISA. Acute B19 infection was defined by the following criteria: positive serum B19-DNA and/or B19 IgM, negative serum B19 IgG, and no other proven infection. RESULTS: Overall, 167 children were included in the study. The mean age was 5.5 +/- 4.6 years (range, 0.5-17), males and females equally divided. Acute B19 infection was demonstrated in 12.6% (n = 21) of the children. Both tests were performed in 19 children and were positive in 10 (53%). In 7 and 2 children, only B19-DNA or B19 IgM, respectively, was positive. Acute B19 infection was documented in 27% (10/39) of children who presented with a variety of acute exanthema diseases; 9% (5/57) of children with acute arthropathy (all 5 had transient synovitis); 10% (2/21) of children with fever >1 week, both presented as mononucleosis syndrome; and in 44% (4/9) of children with transient pancytopenia or aplastic anemia. No acute B19 infection was demonstrated in 15 children with ITP, 9 with HSP, and 6 with aseptic meningitis and among 70 children in the control group. By logistic regression analysis, manifestations significantly associated with acute B19 infection were exanthema (OR 2.9; 95% CI = 1.1-7.5), anemia (OR 6.35; 95% CI = 2.2-18.2) and leucopenia (OR 4.14; 95% CI =1.2-14.2). CONCLUSIONS: Acute B19 infection was documented among 12.6% of children hospitalized with clinical syndrome potentially associated with the virus. Clinical and laboratory features associated with acute B19 infection were exanthema, anemia and leucopenia. Determination of both serum B19-DNA and serum B19 IgM should be performed for the accurate diagnosis of acute B19 infection.

Selected rare, noninfectious syndromes associated with HIV infection.

Infrequent and sometimes treatable noninfectious syndromes associated with HIV disease include tenofovir-associated Fanconi syndrome, a proximal renal tubular disorder; pulmonary hypertension that appears to be due to HIV-driven inflammation resulting in endothelial proliferation; thrombotic thrombocytopenic purpura, characterized by intravascular coagulopathy; diffuse infiltrative lymphocytosis syndrome, which can affect multiple organs; and Castleman's disease, a lymphoproliferative disorder that usually occurs in a multicentric form with poor prognosis in HIV-infected patients. This article summarizes a presentation on the characteristics, diagnosis, treatment, and prognosis of these disorders by Molly E. Eaton, MD, at the International AIDS Society-USA course in Atlanta in March 2005.

Human parvovirus B19-associated thrombocytopenic purpura.

We report two patients who presented with thrombocytopenic purpura (TP) associated with primary human parvovirus B19 (B19) infection. One patient also had transient liver dysfunction. In both cases, B19-DNA was detected in serum and bone marrow by polymerase chain reaction. Six months after the illness in patient 1 and 8 months after the illness in patient 2, B19-DNA disappeared from the serum. Serum immunoglobulin (Ig)G antibody to B19 remained positive in both cases, but B19 IgM antibody became negative 3 months after the onset in case 1 and 4 months after the onset in case 2. The mechanism of TP by B19 infection is unknown.

Immunologic thrombocytopenic purpura as presenting symptom of hepatitis C infection.

We report on 3 female patients with immunologic thrombocytopenic purpura (ITP) for whom diagnostic procedures evidenced a chronic Hepatitis C virus (HCV) infection. In 2 cases, a transfusion performed more than 10 years ago represented the probable way of contamination. One patient received a course of steroids, which normalized the platelet counts. Another one has been treated with repeated IV immunoglobulins, which induced partial responses of variable duration. HCV is responsible for many autoimmune manifestations and a search for this virus seems warranted for exploring patients with ITP.

Autoimmune thrombocytopenic purpura and dermatomyositis associated with chronic hepatitis C. A therapeutic dilemma.

We recently observed a patient with chronic C hepatitis who developed first autoimmune thrombocytopenic purpura and subsequently dermatomyositis. While the association could be coincidental, it is possible that hepatitis C virus could have induced autoantibodies or circulating immune complexes which contributed to both. Although concerns are sometimes raised about the use of corticosteroids and immunosuppressive therapy to control symptoms in hepatitis C virus infected patients with rheumatic or autoimmune diseases, corticosteroid and immunosuppressive therapies are considered appropriate in cases of chronic C hepatitis with rapidly progressive autoimmune diseases. Our case illustrates the paradox that, despite the continuing presence of a viremic form of chronic C hepatitis, clinical symptoms improved with combined immunosuppressive therapy, without deterioration of the hepatitis. Our results could be the consequence of the association of immunosuppressive therapy intensive enough to control the autoimmune thrombocytopenic purpura and dermatomyositis with alpha-interferon whose antiviral capacity may have been able to prevent re-exacerbation of the hepatitis.

Parvovirus B19 infection and idiopathic thrombocytopenic purpura.

The potential association of human parvovirus B19 infection with idiopathic thrombocytopenic purpura (ITP) was studied. All 60 adult patients presenting with ITP at the University Hospital Rotterdam - Dijkzigt during a 12-year period (41 with acute ITP, 19 with chronic ITP) were included. Patient files were retrospectively analyzed. Stored serum samples were tested for parvovirus B19-specific IgG and IgM anti-bodies, and for parvovirus B19 DNA. In only one patient (1.7%) was evidence of recent B19 infection found. Parvovirus B19 is not a frequent cause of adult ITP and should be tested for only when there are other indications of possible parvovirus B19 involvement.