The Christ HospitalThe Christ HospitalApril 2012April 2012

Diana Girnita MD, PhDDiana Girnita MD, PhD

Internal Medicine Internal Medicine Grand RoundsGrand Rounds

Case PresentationCase Presentation

Chief complainsChief complains

72 yo Caucasian F72 yo Caucasian F

ConfusionConfusion

Back pain in the lumbar areaBack pain in the lumbar area

Easy bruisingEasy bruising

Multiple ecchymoses Multiple ecchymoses

What would you like to know?What would you like to know?

HPIHPIMay 2011: fell on the floor and hit her right hip; May 2011: fell on the floor and hit her right hip; has seen a chiropractor has seen a chiropractor For 1 month tried a herbal product, called For 1 month tried a herbal product, called “Willow Bark” (aspirin substitute), did not help“Willow Bark” (aspirin substitute), did not helpOccasionally Ibuprofen 1-2 tablets/ day PRN for Occasionally Ibuprofen 1-2 tablets/ day PRN for many years many years

Two months after fallTwo months after fall– easy bruising with minimal aggressionseasy bruising with minimal aggressions– fatiguedfatigued– weight loss (6-8 Lbs) weight loss (6-8 Lbs)

July 2011: in the ED due to confusion, severe July 2011: in the ED due to confusion, severe back pain rated as 8/10, irradiated in the groin back pain rated as 8/10, irradiated in the groin area, hips and LEsarea, hips and LEs

ROSROSGeneral/ constitutional: General/ constitutional: weight loss 8lbs, + fatigueweight loss 8lbs, + fatigue, no f/c/s, no f/c/s

Skin: Skin: + petechiae, purpura on UEs &LEs and and + petechiae, purpura on UEs &LEs and and ecchymoses lumbar and sacral areasecchymoses lumbar and sacral areas

HEENT:HEENT: no recent changes in vision/ ear pain, occasionalno recent changes in vision/ ear pain, occasional epistaxis epistaxis with ibuprofen intakewith ibuprofen intakeCardiovascular: no palpitations, chest pain, orthopnea, Cardiovascular: no palpitations, chest pain, orthopnea, Respiratory: no dyspnea, cough, hemoptysisRespiratory: no dyspnea, cough, hemoptysisGastrointestinal: no N/V/C/D, melena, hemetemesis Gastrointestinal: no N/V/C/D, melena, hemetemesis GenitourinaryGenitourinary: : no dysuria, changes in urine color, odor or no dysuria, changes in urine color, odor or flow flow Musculoskeletal: no muscle weaknessMusculoskeletal: no muscle weaknessNeurologic: no focal neurologic changesNeurologic: no focal neurologic changes

PMHPMH: none, have not seen a doctor in 20 years: none, have not seen a doctor in 20 years

HOME MEDSHOME MEDS: MULTIVITAMIN po: MULTIVITAMIN po

ALLERGIESALLERGIES: Codeine (Nausea,Vomiting ): Codeine (Nausea,Vomiting )

SURGICAL HX: SURGICAL HX: nonenone

FHXFHX::Cancer, diabetes -MotherCancer, diabetes -MotherCancer, HTN -Father Cancer, HTN -Father

SOCIAL HXSOCIAL HX: Married, G3P3, non-smoker, : Married, G3P3, non-smoker, occasionally alcoholoccasionally alcohol

Physical examinationPhysical examination

VS: temp 97.9/ HR 57/ RR18/VS: temp 97.9/ HR 57/ RR18/BP 168/78BP 168/78/ weight / weight 231lbs231lbs

General:General: obese, well developed, NAD obese, well developed, NADHEENT: HEENT: PERRLA, EOMI, throat non-edematous/ PERRLA, EOMI, throat non-edematous/ erythematous, normal mucoses , erythematous, normal mucoses , no epistaxisno epistaxis

Neck:Neck: normal ROM, nontender, trachea midline, normal ROM, nontender, trachea midline, LN LN nonpalpablenonpalpable/ nontender, no JVD, no carotid bruit / nontender, no JVD, no carotid bruit

CV:CV: RRR, normal S1, S2, no m/r/g RRR, normal S1, S2, no m/r/gResp:Resp: CTA bilaterally without r/r/w CTA bilaterally without r/r/w

Abd:Abd: soft, ND/NT, + BS, soft, ND/NT, + BS, no HSMno HSMExt:Ext: 2+ pulses, without clubbing, cyanosis, or edema 2+ pulses, without clubbing, cyanosis, or edema

Physical examinationPhysical examination

Skin:Skin: warm, dry, warm, dry, – multiple petechiae on her UE &LEmultiple petechiae on her UE &LE– purpurapurpura– ecchymoses more on the UEs, few on LEs, a ecchymoses more on the UEs, few on LEs, a

large ecchymose on the R lumbar arealarge ecchymose on the R lumbar area

Neuro: Neuro: AOx 2 (person, time), CN II-XII AOx 2 (person, time), CN II-XII grossly intact, motor and sensory function grossly intact, motor and sensory function intact with no focal deficitsintact with no focal deficits

What would you like for work up?What would you like for work up?

LabsLabsCBCCBCBMPBMPPT, INR, aPTT, bleeding timePT, INR, aPTT, bleeding timeTSHTSHLiver profileLiver profile

Results- admission at OSHResults- admission at OSH

CBC:CBC:– Hb=10.4; Ht=31.5, MCV 89Hb=10.4; Ht=31.5, MCV 89– WBC =6000/mm3WBC =6000/mm3– Platelets =2000/mm3Platelets =2000/mm3

INR =1.03INR =1.03

TSH -1.54 (WNL)TSH -1.54 (WNL)

ESR =30/1hESR =30/1h

BMP BMP 138

3.8

103

23

0.8

11

Differential Differential diagnosisdiagnosis

CLL / lymphomaCLL / lymphoma

MDSMDS

ITPITP

Collagen disease (APLS, SLE)Collagen disease (APLS, SLE)

TTP, DIC/sepsisTTP, DIC/sepsis

Drugs (NSAIDs, Willow bark/ASA)Drugs (NSAIDs, Willow bark/ASA)

Splenic sequestration/ hypersplenismSplenic sequestration/ hypersplenism

Pseudothrombocytopenia-unikelyPseudothrombocytopenia-unikely

Dilutional s/p massive transfusionDilutional s/p massive transfusion

ImagingImaging

CT head

MRI head

CXR

CT chest/ abdomen/pelvis

Xray of lumbar spine

PET scan

US abdomen – spleen

CT head w/out contrastCT head w/out contrast

Hyperdense intracranial masses compatible with metastatic disease/ possible that these are hyperdense due to blood

MRI headMRI head

MRI impressionMRI impression

Intracranial lesions do not demonstrate Intracranial lesions do not demonstrate significant contrast enhancement as significant contrast enhancement as expected for metastatic diseaseexpected for metastatic disease

Have characteristics compatible with Have characteristics compatible with acute/early subacute blood lossacute/early subacute blood loss

Multifocal intraparenchymal brain Multifocal intraparenchymal brain hemorrhagehemorrhage

CXRCXR

CT chest, abdomen, pelvisCT chest, abdomen, pelvis

CT chest, abdomen, pelvis CT chest, abdomen, pelvis impressionimpression

No mass or adenopathy in the chest, No mass or adenopathy in the chest, abdomen, pelvisabdomen, pelvis

Bilateral pulmonary ground glass infiltratesBilateral pulmonary ground glass infiltrates

Likely alveolar hemorrhageLikely alveolar hemorrhage

US spleen -normalUS spleen -normal

X-ray lumbar spineX-ray lumbar spine

No fracture, Mild scoliosisNo fracture, Mild scoliosis

Degenerative disc disease:L2-L3, L4-L5Degenerative disc disease:L2-L3, L4-L5

PET scanPET scan

nonoevidence evidence of skeletal of skeletal metastatic metastatic

diseasedisease

What do we know so far?What do we know so far?

Critical platelets counts Critical platelets counts

Multiorgan hemorrhagesMultiorgan hemorrhages

OSH treatmentOSH treatment

8U of platelets8U of platelets

Decadron iv 4mg Q6HDecadron iv 4mg Q6H

One dose of IVIG =1mg/kg (1000mg)One dose of IVIG =1mg/kg (1000mg)

Platelets remained in the 2-3000/mm3Platelets remained in the 2-3000/mm3

Patient was transferred to TCHPatient was transferred to TCH

TCH work-upTCH work-up

CBC: CBC: –WBC=6000/mm3, WBC=6000/mm3, –H/H = 8.2/24.8,MCV =91 H/H = 8.2/24.8,MCV =91 –Platelets =3000/mm3Platelets =3000/mm3

BMP -normalBMP -normal

Anemia work-upAnemia work-upRetic count -110976 (H)Retic count -110976 (H)

LDH -269 (H)LDH -269 (H)

Haptoglobin 64 (N)Haptoglobin 64 (N)

COOMBS test and RH positiveCOOMBS test and RH positive

Iron studies: normalIron studies: normal

Vit B12/folate were normalVit B12/folate were normal

Peripheral smear: no schystocytesPeripheral smear: no schystocytes

TCH work-upTCH work-up

Liver tests were normalLiver tests were normal

TSH -0.23 (L)TSH -0.23 (L)

Fecal occult test -NEGATIVEFecal occult test -NEGATIVE

TCH work-upTCH work-upFibrinogen – 307 (range 175-425)Fibrinogen – 307 (range 175-425)

INR -1.3 (0.9-1.1)INR -1.3 (0.9-1.1)

PT – 16.1 (11.9-14.8)PT – 16.1 (11.9-14.8)

aPTT -23.5 (23.6-33.5)aPTT -23.5 (23.6-33.5)

Serum protein electrophoresisSerum protein electrophoresis– Alpha1,2; beta normalAlpha1,2; beta normal– Gamma globulin 3.9 (H)Gamma globulin 3.9 (H)– Globulin 4 (H)Globulin 4 (H)– Albumin (3.2) Albumin (3.2)

Kappa/lambda ratio –normalKappa/lambda ratio –normal

– Kappa-12.5 (3.3-14)Kappa-12.5 (3.3-14)

– Lambda -14.10 (5.7-26.3)Lambda -14.10 (5.7-26.3)

– Ratio – 0.89 (0.26-1.65)Ratio – 0.89 (0.26-1.65)

Parvovirus B 19 IgG positive, no IgMParvovirus B 19 IgG positive, no IgM

Consult to hematology Consult to hematology

Bone Marrow biopsyBone Marrow biopsy

Cellularity is 85%. Cellularity is 85%.

Hyperplasia of the erythroid, as well as the Hyperplasia of the erythroid, as well as the megakaryocyte series with normal megakaryocyte series with normal morphologic features.morphologic features.

Dysplasia is not evident.Dysplasia is not evident.

Findings most compatible with peripheral Findings most compatible with peripheral platelet destruction.platelet destruction.

Bone marrow biopsyBone marrow biopsy

Special STAINS:Special STAINS:

Storage iron decreased.Storage iron decreased.

Reticulin stain shows no increase in Reticulin stain shows no increase in reticulin fibrosisreticulin fibrosisPAS stain highlights the megakaryocyte PAS stain highlights the megakaryocyte population population

ITP diagnosis and therapyITP diagnosis and therapy

IVIG

WinRho

Rituximab 1st Rituximab 2nd

Splenectomy

Methyprednisolone, f/b PDN taper

1st 2nd

Question Question

Why was this patient refractory to Why was this patient refractory to platelet transfusions therapy ?platelet transfusions therapy ?

PlateletsPlatelets

Glycoproteins (GP)Glycoproteins (GP)

GP Ib/IX =receptor for GP Ib/IX =receptor for VWFVWF

GP IIb/IIIa = receptor for GP IIb/IIIa = receptor for fibrinogenfibrinogen

GP Ia/IIa = collagen GP Ia/IIa = collagen receptor.receptor.

HLA class I: A, BHLA class I: A, B

The cell surface is a jungle!!

Gebel and Bray, Transplantation 2004

0

100

200

300

400

500

600

A B C DRB1

1990

1997

2001

2002

2004 N > 2400

HLA -A and B are important in HLA -A and B are important in platelet transfusionplatelet transfusion

Refractoriness to platelet Refractoriness to platelet transfusiontransfusion

ELISA-positive for:ELISA-positive for:

platelet-specific antibodies (1a, 1b, 3a, 3b, platelet-specific antibodies (1a, 1b, 3a, 3b, 4a, 5a, 5b) and4a, 5a, 5b) and

HLA-specific antibodiesHLA-specific antibodies

Broad IgG reactivity towards HLA Broad IgG reactivity towards HLA antigens determined by Luminex antigens determined by Luminex

single-antigen beadssingle-antigen beads

Calculated PRA = 82%

SELF HLA -NEGATIVE

The high (82%) allo-reactivity was The high (82%) allo-reactivity was explained by only two specificities: explained by only two specificities: anti-HLA A3 (private epitope) and anti-HLA A3 (private epitope) and

anti-HLA w4 (public epitope) anti-HLA w4 (public epitope)

A3

W4 epitope

The w4 epitope (78-82 RENLR) is known as The w4 epitope (78-82 RENLR) is known as a very immunogenic public epitopea very immunogenic public epitope

Magenta – Heavy Chain (Alpha chain)Blue – Light chain (Beta-2 microglobulin)Brown – PeptideYellow – Bw4 epitope

Patient had no previous transplants Patient had no previous transplants and/or transfusions;and/or transfusions;Three pregnancies;Three pregnancies;

Patient and husband HLA typing Patient and husband HLA typing

Husband’s mismatched HLA class I:A3

B57 (bearing the Bw4 epitope)

Antibodies towards HLA class II Antibodies towards HLA class II were also explained by pregnancy were also explained by pregnancy

sensitizationsensitization

Husband’s mismatched HLA: DR7, DR17, DQ2, DQ9

The IgG subtype analysis demonstrated The IgG subtype analysis demonstrated IgG1, which is a strong complement binderIgG1, which is a strong complement binder

IMMUNE IMMUNE TROMBOCYTOPENIA TROMBOCYTOPENIA

(ITP)(ITP)

Immune thrombocytopenia vs ITPImmune thrombocytopenia vs ITP

can no longer be considered idiopathiccan no longer be considered idiopathic

DefinitionDefinition

– Platelet count < 100 x 10Platelet count < 100 x 1099/L/L– No other cause of thrombocytopenia No other cause of thrombocytopenia – No No clinically evident clinically evident secondary form secondary form

Rodeghiero F, et al. Blood. 2009;113:2386-2393

Timing in ITPTiming in ITP

Newly Newly diagnosed < 3 modiagnosed < 3 mo

Persistent ITPPersistent ITP – 3 -12 mo and patients not – 3 -12 mo and patients not reaching/maintaining remission off therapyreaching/maintaining remission off therapy

Chronic ITP: > Chronic ITP: > 12 mo12 mo

Primary ITP – mechanismsPrimary ITP – mechanisms–molecular mimicrymolecular mimicry–epitope spreadepitope spread

Primary vs Secondary ITPPrimary vs Secondary ITP

Molecular mimicryMolecular mimicry

HIV HCV H. pylori

ITP Post-infection:ITP Post-infection:Molecular Mimicry GPIIIa (aa 49-66)Molecular Mimicry GPIIIa (aa 49-66)

Nardi MA, et al. Proc Natl Acad Sci U S A. 1997;94:7589-7594. 2. Zhang W, et al. Blood. 2009;113:4086-4093. 3. Takahashi T, et al. Br J Haematol. 2004;124:91-96.

EPITOPE SPREADEPITOPE SPREAD

Cines DB,Cines DB,

NEJM 2002;NEJM 2002;

346:995-1008346:995-1008

Alloantibodies determineAlloantibodies determine

–reduced platelet survival reduced platelet survival

– impaired platelet production impaired platelet production (megakaryocytes)(megakaryocytes)

Prevalence of Prevalence of SecondarySecondary ITP ITP

SLE 5%

APS 2%

CVID 1%

CLL 2%

Evan’s 2%

ALPS, post-tx 1%HIV 1%

Hep C 2%

H. pylori 1%Postvaccine 1%

Misc systemic infection 2%

Primary80%

Cines DB, et al. Blood. 2009;113:6511-6521.

Initial Evaluation for ITP 2010Initial Evaluation for ITP 2010

ASH: CBC, blood smear, BM (age > 60 ASH: CBC, blood smear, BM (age > 60 yrs), r/o other causesyrs), r/o other causes

Infection: HIV, HCV, HBV, H. pylori, PPDInfection: HIV, HCV, HBV, H. pylori, PPD

Autoimmune: ANA, APLA, ATA/TSHAutoimmune: ANA, APLA, ATA/TSH

Secondary: DAT, reticulocytes, LFTs, CT Secondary: DAT, reticulocytes, LFTs, CT scan/echo scan/echo

Bone marrow: reticulin at baseline?Bone marrow: reticulin at baseline?

Provan D, et al. Blood. 2010 115: 168-186

BM> 60 yrs BM> 60 yrs to exclude MDS/ CLLto exclude MDS/ CLL

Quantitative IG before patients receive IVIG (CVID Quantitative IG before patients receive IVIG (CVID or IgA deficiency)or IgA deficiency)

Direct antiglobulin testDirect antiglobulin test - - 22% pt have DAT+ 22% pt have DAT+

Blood group Rh(D) typingBlood group Rh(D) typing :: if treatment with anti- if treatment with anti-RhD immunoglobulin is being consideredRhD immunoglobulin is being considered

1. Provan D, et al. Blood. 2010. 2. Cines DB, et al. Blood. 2009;113:6511-6521.

Additional TestsAdditional TestsThyroglobulin antibodies and/or TSHThyroglobulin antibodies and/or TSH -8% to 14% ITP -8% to 14% ITP can develop hyperthyroidism; the presence of can develop hyperthyroidism; the presence of hyper/hypothyroidism result in resistance to therapyhyper/hypothyroidism result in resistance to therapy

ANA ANA is predictive of chronicity in childhood ITPis predictive of chronicity in childhood ITP

H/o fetal loss/ thrombosis- H/o fetal loss/ thrombosis- antiphospholipid antibodiesantiphospholipid antibodies 15% have ITP15% have ITP

1. Provan D, et al. Blood. 2009;[Epub ahead of print]. 2. Liebman H. Semin Hematol. 2007;44(4 suppl 5): S24-S34. 3. Altintas A, et al. J Thromb Thrombolysis. 2007;24:163-168.

Treatment in ITPTreatment in ITP

Timeline: introduction of modern Timeline: introduction of modern day ITP drug treatmentday ITP drug treatment

Splenectomy

Corticosteroids

IVIg

Anti-D

Rituximab

TPO mimetics

1900 1920 1960 20001940 1980

ITPITPWho and When to TreatWho and When to Treat

Only platelet # < 20-30 x 10Only platelet # < 20-30 x 1099/L or /L or symptomaticsymptomatic

Bleeding risk > 60 yrsBleeding risk > 60 yrs

Post-splenectomy Post-splenectomy

Bleeding and infection contribute equally Bleeding and infection contribute equally to mortalityto mortality

Provan D, et al. Blood. 2010 115: 168-186

Relevant factors: Relevant factors:

– extent of bleedingextent of bleeding– comorbidities predisposing to bleedingcomorbidities predisposing to bleeding– complications of specific therapiescomplications of specific therapies– activity and lifestyleactivity and lifestyle– potential interventions that may cause potential interventions that may cause

bleedingbleeding– patient expectations, anxietypatient expectations, anxiety

CorticosteroidsCorticosteroids

IVIg and Anti-D (Winrho)IVIg and Anti-D (Winrho)

Rituximab (anti CD20 mAb)Rituximab (anti CD20 mAb)

Splenectomy –removes B and plasma Splenectomy –removes B and plasma cellscells

Anti-plasma cell drugs (proteasome Anti-plasma cell drugs (proteasome inhibitors)inhibitors)

TPO mimmeticsTPO mimmetics

ITPITPHow to TreatHow to Treat

Rajan Lakhia, MDSuzanne Partridge, MDHoxworth Blood Center

Treatment Strategy

Response Rate

Time to Response

Response Duration

Cortico-steroids

Prednisone 70-80% Several days to weeks

Uncertain

Me-Pred ≤ 95% Few days 23% have > 50x109/L at 39 months

Immune Globulin

IVIg ≥ 80% 1-2 days 3-4 weeks, months in some

Anti-D: 50-80% (dose dependent)

1-5 days (dose dependent)

Typically 3–4 weeks, months in some

Provan D, et al. Blood. 2009;[

Frontline Therapies -Adult ITPFrontline Therapies -Adult ITP

IV Immune globulin (IVIg)IV Immune globulin (IVIg)

Mechanism of actionMechanism of action– Effects on humoral and cellular immune functionEffects on humoral and cellular immune function11 – Impairs of clearance of opsonized plateletsImpairs of clearance of opsonized platelets11

Effect mediated through FcγRIIb receptor (murine Effect mediated through FcγRIIb receptor (murine model)model)22

– Increases clearance of antiplatelet antibodies via Increases clearance of antiplatelet antibodies via saturation of the FcRn (rodent model)saturation of the FcRn (rodent model)33

1. Sandler and Tutuncuoglu. Expert Opin Pharmacother. 2004;5:2515-2527. 2. Samuelsson et al. Science. 2001;291:484-486. 3. Hansen and Balthasar. Blood. 2002;100:2087-2093. 4. George J, et al. Blood. 1996;88:3-40.

Rituximab Rituximab

Anti-CD20 monoclonal antibodyAnti-CD20 monoclonal antibody

Hypothesis: B-cell depletion: ? Hypothesis: B-cell depletion: ? ↓ antiplatelet ↓ antiplatelet antibodiesantibodies

No RCT studies availableNo RCT studies available

Effective dose not known, not FDA-approved Effective dose not known, not FDA-approved

Before splenectomy, when the surgical Before splenectomy, when the surgical option is not well accepted/ high risk of option is not well accepted/ high risk of complicationscomplications

SplenectomySplenectomy

Mechanism of actionMechanism of action– Removes a primary site of platelet destruction Removes a primary site of platelet destruction

by macrophagesby macrophages– Possible site of autoantibody productionPossible site of autoantibody production

Sandler SG, et al. Expert Opin Pharmacother. 2004;5:2515-2527.

Splenectomy: complete response Splenectomy: complete response vs timevs time

47 case series, adults only, f/u median: 29 mos (range: 1-153)

Kojouri K, et al. Blood. 2004;104:2623-2634.

0

20

40

60

80

100

0 40 160

Follow-up (Mos)

% C

ompl

ete

Rem

issi

on

20 8060 100 140120

r = -0.1031, P = .490

Kosugi S, et al. Br J Haematol. 1996;93:704-706. Copyright © 1996. Reproduced with permission of John Wiley & Sons, Inc.

Patient Group

Anaplastic anemia(n = 12)

Now vs thenNow vs then

30

ITP(n = 43)

Normal(n = 21)

TP

O (

fem

tom

oles

/mL)

25

15

20

10

5

0

Plasma TPO Levels in ITP

1) healthy: platelet # is high and serum thrombopoietin is low2) ITP: both the platelet # and serum thrombopoietin levels are low3)AA: platelet # low, but serum thrombopoietin levels are high

% C

ontr

ol

Meg

akar

yocy

tes

Suppression of Megakaryocyte Suppression of Megakaryocyte Production by ITP PlasmaProduction by ITP Plasma

100

75

50

25

0ITP-1 ITP-2 ITP-3 ITP-4 ITP-5 ITP-6 ITP-7 ITP-8 ITP-9 ITP-10 ITP-11 ITP-12

McMillan R, et al. Blood. 2004;103:1364-1369.