Autoimmune Thrombocytopenic Purpura and Common Variable Immunodeficiency

Abstract

To describe the main characteristics and outcome of autoimmune thrombocytopenic purpura (AITP) in patients with common variable immunodeficiency (CVID), we analyzed data from 21 patients and reviewed additional cases from the literature. To be included in this study, patients had to have CVID and a previous history of AITP with a platelet count < or = 50 x 10(9)/L at onset. A complete response to treatment was defined by a platelet count > or = 150 x 10(9)/L, and a partial response by a platelet count >>50 x 10(9)/L with an increase of at least twofold the initial level. The median platelet count at AITP diagnosis was 20 x 10(9)/L (range, 2-50 x 10(9)/L). The median age at AITP diagnosis was 23 years (range, 1-51 yr), whereas the median age at CVID diagnosis was 27 years (range, 10-74 yr). CVID was diagnosed before the onset of AITP in only 4 patients (19%), 3 of whom were being treated with intravenous immunoglobulin (i.v.Ig) replacement therapy. CVID was diagnosed more than 6 months after AITP in 13 cases (62%), and the 2 conditions were diagnosed concomitantly in 4 cases. Eleven patients (52%) had at least 1 autoimmune manifestation other than AITP, among which autoimmune hemolytic anemia (7 cases) and autoimmune neutropenia (5 cases) were preeminent. Seventeen of the 21 patients (80%) received at least 1 treatment for AITP; 13 patients received corticosteroids alone and 7 (54%) achieved at least a partial response; 8 patients received i.v.Ig at 1-2 g/kg alone or in combination with steroids, leading to a short-term response rate of 50%. Four patients underwent a splenectomy (2 complete responses, 2 failures); 2 additional splenectomies were performed for associated autoimmune hemolytic anemia. With a mean follow-up of 5.6 years after the surgical procedure, none of the 6 splenectomized patients had a life-threatening infection. With a median follow-up after AITP onset of 12 years, 13/21 patients (62%) were in treatment-free remission (7 complete responses, 6 partial responses), 7 patients (23%) were in remission while on prednisone < or = 20 mg/day with or without azathioprine, and only 1 patient still had a platelet count <50 x 10(9)/L. Five patients had died at the time of the analysis; none of the deaths was related to a hemorrhage. Severe infections including 3 fatal bacterial infections and 2 opportunistic infections occurred in 6 patients during or after treatment of AITP. In conclusion, AITP, alone or in combination with autoimmune hemolytic anemia (Evans syndrome) and/or autoimmune neutropenia, is frequent in patients with CVID, and is not prevented by i.v.Ig substitutive therapy. Since AITP frequently precedes the diagnosis of CVID, testing for immunoglobulin levels should be performed in every patient diagnosed with AITP. Steroids and splenectomy seem to have the same efficacy as in idiopathic AITP, but the increased risk of severe infections must be taken into consideration.

The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia

“…ITP can be a presenting feature of CVID, in one series of patients with CVID and ITP 17/21 presented with ITP alone. 16 The utility of screening all ITP patients for CVID, however, is unclear.…”

Pathogenesis, Diagnosis, and Management of Primary Antibody Deficiencies and Infections

“…As an example, a study of 21 patients with CVID and immune thrombocytopenic purpura revealed that CVID was diagnosed in only 19% of cases prior to the onset of immune thrombocytopenic purpura (88). Other clinical features associated with PAD can be clues for diagnosis, such as granulomatous disease, splenomegaly, unexplained chronic lung disease, unexplained chronic gastrointestinal disease, or inflammatory arthropathy (32,64,111).…”

Autoimmune Manifestations in Common Variable Immunodeficiency

“…In most cases, the treatment of autoimmunity in CVID is the same as for immune competent subjects [4,6] with the caveat that when immune suppression is used, lower doses and shorter periods of treatment are advisable, as opportunistic and or fatal complication infections become more likely with prolonged or excessive treatment (Table I). For ITP and AIHA, increased doses of immune globulin may be helpful.…”