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Helicobacter pylori associated with idiopathic thrombocytopenic purpura

2002; Elsevier BV; Volume: 113; Issue: 2 Linguagem: Inglês

10.1016/s0002-9343(02)01134-8

1555-7162

Masaya Mukai, Yujiro Kon, Atsushi Notoya, Michifumi Kohno,

Gastrointestinal disorders and treatments

Helicobacter pylori infection has been associated with gastric cancer and lymphoma. However, it has also been reported that H. pylori infection is associated with some autoimmune diseases (1Gasbarrini A. Franceschi F. Autoimmune diseases and Helicobacter pylori infection.Biomed Pharmacother. 1999; 53: 223-226Crossref PubMed Scopus (63) Google Scholar), especially idiopathic thrombocytopenic purpura (2Gasbarrini A. Franceschi F. Tartaglione R. et al.Regression of autoimmune thrombocytopenia after eradication of Helicobacter pylori.Lancet. 1998; 352 ([letter]): 878Abstract Full Text Full Text PDF PubMed Scopus (372) Google Scholar). In some cases, the eradication of H. pylori led to resolution of refractory idiopathic thrombocytopenic purpura (3Grimaz S. Damiani D. Brosolo P. et al.Resolution of thrombocytopenia after treatment for Helicobacter pyloria case report.Haematologica. 1999; 84: 283-284PubMed Google Scholar, 4Garcia Perez A. Valverde de La Osa J. Gimenez Samper M. Alonso Garcia I. Resolution of an autoimmune thrombocytopenic purpura after eradicating treatment of Helicobacter pylori.Sangre. 1999; 44 ([in Spanish]): 387-388PubMed Google Scholar, 5Tohda S. Ohkusa T. Resolution of refractory idiopathic thrombocytopenic purpura after eradication of Helicobacter pylori.Am J Hematol. 2000; 65: 329-330Crossref PubMed Scopus (28) Google Scholar, 6Emilia G. Longo G. Luppi M. et al.Helicobacter pylori eradication can induce platelet recovery in idiopathic thrombocytopenic purpura.Blood. 2001; 97: 812-814Crossref PubMed Scopus (212) Google Scholar, 7Goto H. Kikuta T. Ota A. et al.Successful treatment of refractory idiopathic thrombocytopenic purpura by eradication of Helicobacter pylori.Rinsho Ketsueki. 2001; 42 ([in Japanese]): 1192-1194PubMed Google Scholar). We report two patients with idiopathic thrombocytopenic purpura, who were resistant to treatment with high-dose steroids, but who responded when H. pylori was eradicated. The first patient, a 51-year-old man, was diagnosed with thrombocytopenia (8000/μL) in July 2001, and was treated with high-dose steroids for 2 months, which had little effect (Figure). He underwent irradiation of the spleen in August, and his platelet count increased to 45,000/μL by September. Measurement of platelet life span revealed a half-life of 4.7 days (normal, 8.4 days), and splenic uptake was elevated (the ratios of platelet uptake were 4.79 for spleen to heart, 1.97 for liver to heart, and 0.28 for sacral bone to heart). Although splenectomy was proposed to treat his thrombocytopenia, a 13C-urea breath test was positive (60.1‰; normal, <2.5‰). The patient was treated with clarithromycin (200 mg twice daily), metronidazole (250 mg three times daily), and lansoprazole (30 mg twice daily) for 7 days to eradicate the organism, during which his platelet count increased and, after a month of treatment, reached 220,000/μL. The second patient, a 62-year-old woman, had oral bleeding since November 2001. She was diagnosed with thrombocytopenia (2000/μL) and was treated with high-dose steroids and high-dose intravenous gamma globulin (400 mg/kg per day for 5 days), without any effect. Because she was likely to bleed, a urea breath test was inappropriate. However, because she was antibody-positive for H. pylori (6.2 EV; normal range, <1.7 EV), treatment with clarithromycin (200 mg twice daily), amoxicillin (750 mg twice daily), and lansoprazole (30 mg twice daily) for 7 days was undertaken from early December. Her platelet count increased to 28,000/μL about a week later. After therapy, the prednisolone dose was tapered rapidly to 10 mg/d, and her platelet count increased to 118,000/μL in mid-December. After Gasbarrini et al. (2Gasbarrini A. Franceschi F. Tartaglione R. et al.Regression of autoimmune thrombocytopenia after eradication of Helicobacter pylori.Lancet. 1998; 352 ([letter]): 878Abstract Full Text Full Text PDF PubMed Scopus (372) Google Scholar) reported the effects of H. pylori eradication on idiopathic thrombocytopenic purpura, other reports suggested that this therapy also induced recovery from refractory idiopathic thrombocytopenic purpura (3Grimaz S. Damiani D. Brosolo P. et al.Resolution of thrombocytopenia after treatment for Helicobacter pyloria case report.Haematologica. 1999; 84: 283-284PubMed Google Scholar, 4Garcia Perez A. Valverde de La Osa J. Gimenez Samper M. Alonso Garcia I. Resolution of an autoimmune thrombocytopenic purpura after eradicating treatment of Helicobacter pylori.Sangre. 1999; 44 ([in Spanish]): 387-388PubMed Google Scholar, 5Tohda S. Ohkusa T. Resolution of refractory idiopathic thrombocytopenic purpura after eradication of Helicobacter pylori.Am J Hematol. 2000; 65: 329-330Crossref PubMed Scopus (28) Google Scholar, 6Emilia G. Longo G. Luppi M. et al.Helicobacter pylori eradication can induce platelet recovery in idiopathic thrombocytopenic purpura.Blood. 2001; 97: 812-814Crossref PubMed Scopus (212) Google Scholar, 7Goto H. Kikuta T. Ota A. et al.Successful treatment of refractory idiopathic thrombocytopenic purpura by eradication of Helicobacter pylori.Rinsho Ketsueki. 2001; 42 ([in Japanese]): 1192-1194PubMed Google Scholar). However, the mechanism by which H. pylori induces thrombocytopenia is unknown. Because thrombocytopenia is very refractory to steroids, and the eradication of H. pylori can rapidly initiate recovery, cross-reactivity between H. pylori and platelets is unlikely. Because irradiation of the spleen was partially effective in our first patient, it is possible that the activation of splenic functions by factors excreted by H. pylori underlies the pathogenesis of thrombocytopenia. Physicians should recognize that some cases of idiopathic thrombocytopenic purpura are not “idiopathic,” but are induced by H. pylori. When H. pylori infection is demonstrable, eradication of the organism should be undertaken in the treatment of patients with refractory thrombocytopenia.