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DOI: 10.1055/a-2159-8722
Management of Recurrent Venous Thromboembolism in Severe Immune Thrombocytopenia: A Case Report and a Review of the Literature
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Abstract
We report a case of a 58-year-old man with recurrent unprovoked deep vein thrombosis (DVT) and severe immune thrombocytopenia (ITP) with a platelet count of 19 × 109/L. We further review studies reporting venous thromboembolism (VTE) in patients with severe ITP (≤ 35 × 109/L) and identified 14 patients highlighting VTE risk factors and management of these patients. The present case had several risk factors for VTE (previous DVT, obesity, heterozygosity for factor V Leiden mutation, and previous splenectomy). The patient was initially treated with low-molecular-weight heparin followed by long-term apixaban treatment. The literature review together with our case demonstrates that VTE in severe ITP (≤ 35 × 109/L) can occur in patients with VTE risk factors and antithrombotic management of these patients can be achieved without bleeding depending on severity of thrombocytopenia either by full or reduced dose of anticoagulation together with ITP therapy.
Statement of Ethics
An ethical review is not required for this type of article. The patient is aware that his clinical details are used in this article. Written consent was given by the patient.
Authors' Contributions
M.H.N. performed the literature review, interpreted the data, and wrote the first draft of the manuscript and approved the final manuscript.
M.V.B. planned the study, supervised for the recruitment of the subject, performed the literature review, interpreted the data, and supervised the writing of the manuscript, and approved the final manuscript.
Data Availability
The data supporting the findings of this study are available on request due to privacy/ethical restrictions.
Publication History
Received: 17 April 2023
Accepted: 23 August 2023
Article published online:
31 October 2023
© 2023. Thieme. All rights reserved.
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References
- 1 Le Guenno G, Guieze R, Audia S. et al. Characteristics, risk factors and management of venous thromboembolism in immune thrombocytopenia: a retrospective multicentre study. Intern Med J 2019; 49 (09) 1154-1162
- 2 Nørgaard M, Cetin K, Maegbaek ML. et al. Risk of arterial thrombotic and venous thromboembolic events in patients with primary chronic immune thrombocytopenia: a Scandinavian population-based cohort study. Br J Haematol 2016; 174 (04) 639-642
- 3 Rodeghiero F. Is ITP a thrombophilic disorder?. Am J Hematol 2016; 91 (01) 39-45
- 4 Arnold DM. Bleeding complications in immune thrombocytopenia. Hematology (Am Soc Hematol Educ Program) 2015; 2015: 237-242
- 5 Klok FA, Hösel V, Clemens A. et al. Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment. Eur Respir J 2016; 48 (05) 1369-1376
- 6 Lee YJ, Shin JU, Lee J. et al. A case of deep vein thrombosis and pulmonary thromboembolism after intravenous immunoglobulin therapy. J Korean Med Sci 2007; 22 (04) 758-761
- 7 Ho P, Khan S, Crompton D, Hayes L. Extensive cerebral venous sinus thrombosis after romiplostim treatment for immune thrombocytopenia (ITP) despite severe thrombocytopenia. Intern Med J 2015; 45 (06) 682-683
- 8 İlhan G, Toprak SK, Andıç N, Karakuş S. Idiopathic thrombocytopenic purpura with venous thrombosis: a case report. Turk J Haematol 2010; 27 (03) 209-210
- 9 Takeuchi T, Matsuura Y, Yamamura Y. et al. A likely unavoidable clinical scenario during treatment for venous thromboembolism complicated with severe immune thrombocytopenia: a case report. Clin Case Rep 2021; 9 (09) e04805
- 10 Kang J, Lee JS, Lee JH, Lee KM. Recurrent pulmonary embolism during dabigatran treatment in a patient with immune thrombocytopenic purpura. Thromb Res 2016; 148: 23-24
- 11 Tan Y, Yan M, Cheng Z, Pan X. Pulmonary thromboembolism in immune thrombocytopenia: a report of five cases and a review of the literature. Int J Gen Med 2021; 14: 4479-4483
- 12 Ennis G, Domingues N, Silva Marques J, Ribeiro P, Andrade C. Cerebral venous thrombosis and its clinical diversity. Cureus 2021; 13 (04) e14750
- 13 Indolfi G, Bartolini E, Resti M. Differential diagnosis between immune (idiopathic) thrombocytopenic purpura and portal vein thrombosis in children. Eur J Haematol 2009; 83 (06) 607-608
- 14 Han X, Li C, Zhang S. et al. Why thromboembolism occurs in some patients with thrombocytopenia and treatment strategies. Thromb Res 2020; 196: 500-509
- 15 Rand ML, Dean JA. Platelet function in autoimmune (idiopathic) thrombocytopenic purpura. Acta Paediatr Suppl 1998; 424: 57-60
- 16 Luo S, Hu D, Wang M, Zipfel PF, Hu Y. Complement in hemolysis- and thrombosis- related diseases. Front Immunol 2020; 11: 1212
- 17 Kim KJ, Baek IW, Yoon CH, Kim WU, Cho CS. Thrombotic risk in patients with immune thrombocytopenia and its association with antiphospholipid antibodies. Br J Haematol 2013; 161 (05) 706-714
- 18 Boyle S, White RH, Brunson A, Wun T. Splenectomy and the incidence of venous thromboembolism and sepsis in patients with immune thrombocytopenia. Blood 2013; 121 (23) 4782-4790
- 19 Swan D, Newland A, Rodeghiero F, Thachil J. Thrombosis in immune thrombocytopenia - current status and future perspectives. Br J Haematol 2021; 194 (05) 822-834
- 20 Shaheen K, Alraies MC, Alraiyes AH, Christie R. Factor V Leiden: how great is the risk of venous thromboembolism?. Cleve Clin J Med 2012; 79 (04) 265-272
- 21 Hui C, Brodsky RA, Haines C. Bilateral pulmonary embolism with right heart strain in a patient with immune thrombocytopenia - a case report and review of the literature. Pediatr Emerg Care 2020; 36 (04) e227-e228
- 22 Adelborg K, Kristensen NR, Nørgaard M. et al. Cardiovascular and bleeding outcomes in a population-based cohort of patients with chronic immune thrombocytopenia. J Thromb Haemost 2019; 17 (06) 912-924
- 23 Balitsky AK, Kelton JG, Arnold DM. Managing antithrombotic therapy in immune thrombocytopenia: development of the TH2 risk assessment score. Blood 2018; 132 (25) 2684-2686
- 24 Bolton-Maggs PHB, George JN. Immune thrombocytopenia treatment. N Engl J Med 2021; 385 (10) 948-950
- 25 Cuker A, Liebman HA. Corticosteroid overuse in adults with immune thrombocytopenia: cause for concern. Res Pract Thromb Haemost 2021; 5 (06) e12592
- 26 Brotman DJ, Girod JP, Posch A. et al. Effects of short-term glucocorticoids on hemostatic factors in healthy volunteers. Thromb Res 2006; 118 (02) 247-252
- 27 Ramírez E, Romero-Garrido JA, López-Granados E. et al. Symptomatic thromboembolic events in patients treated with intravenous-immunoglobulins: results from a retrospective cohort study. Thromb Res 2014; 133 (06) 1045-1051
- 28 Provan D, Arnold DM, Bussel JB. et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3 (22) 3780-3817
- 29 Refaai MA, Phipps RP, Spinelli SL, Blumberg N. Platelet transfusions: impact on hemostasis, thrombosis, inflammation and clinical outcomes. Thromb Res 2011; 127 (04) 287-291
- 30 Ghanima W, Lee SY, Barsam S, Miller A, Sandset PM, Bussel JB. Venous thromboembolism and coagulation activity in patients with immune thrombocytopenia treated with thrombopoietin receptor agonists. Br J Haematol 2012; 158 (06) 811-814