Characteristics and outcomes of adults with cytomegalovirus‐associated thrombocytopenia: a case series and literature review

Abstract

Cytomegalovirus (CMV) is a ubiquitous virus that infects people worldwide. CMV is known to trigger thrombocytopenia, but this association is probably underdiagnosed since CMV infection in healthy adults is usually either asymptomatic or causes only mild symptoms. A systematic literature review was carried out and yielded 23 publications that reported 25 patients. All haematology centres in Israel were searched for adult immunocompetent patients with CMV-associated thrombocytopenia, and five new cases were identified. The median age of the combined 30 patients was 33 years (range 18-80), 73% were men, 77% presented with CMV-related symptoms, 48% had enlarged spleens, 95% had atypical lymphocytes in peripheral blood and 68% had elevated transaminase levels. The response rate to first-line steroid-containing regimens was only 31%, whereas 11 patients who were treated with an anti-CMV agent had a response rate of 82%. Moreover, four patients received thrombopoietin receptor agonists (TPO-RA) to which three (75%) responded. Taken together, these distinctive features of a case with thrombocytopenia should alert to CMV infection as the source. While steroids were effective in less than one-third of the cases, both anti-CMV therapy and TPO-RA exhibited excellent efficacy, suggesting that those agents should be introduced earlier in the therapeutic course.

Yoğun bakım ünitesinde lenfoma tanısı ile takip edilen hastalarda sağkalımı etkileyen faktörler

“…In the current research, neutrophil counts were statistically lower in nonsurvivors yet remained above 1.5 (x10³/mL). Various etiological factors may induce thrombocytopenia, including certain infections like COVID-19 pneumonia and cytomegalovirus infection or antimicrobial agents like linezolid [22][23][24] . In our cohort of non-survivors, platelet counts and SOFA scores were clinically significantly low and high, respectively.…”

HCMV modulates c‐Mpl/IEX‐1 pathway‐mediated megakaryo/thrombopoiesis via PDGFRα and αvβ3 receptors after allo‐HSCT

“…Similarly, there was a trend of higher TPO levels in patients with aplastic anemia (AA; Marsh et al, 1996), and TPO mimetics were approved by the Food And Drug Administration (FDA) for use as a single agent in severe AA patients refractory to frontline immunosuppressive therapy due to its stimulatory effect on HSCs and early progenitor cells (Pierri & Dufour, 2019). A literature review (Shragai et al, 2020) of studies involving adult immunocompetent patients with HCMV-associated thrombocytopenia concluded that eltrombopag exhibited excellent efficacy with a response rate of 75%, and it needs to be further assessed in large clinical samples as a potential treatment for HCMV-infected patients with thrombocytopenia.…”

“…The first theory suggests that HCMV infection results in damage to the hematopoietic microenvironment, leading to reduced growth factor production and mesenchymal stem cell (MSC) renewal. An impaired microenvironment results in cytopenia and contributes to graft failure in patients after HSCT (Kong et al, 2014; Smirnov et al, 2007). The second theory suggests that autoantibodies that are detected in HCMV‐positive patients (Yaari et al, 2010) directly interact with the platelet membrane or mediate the elimination of immune complexes by the monocyte–macrophage system.…”

Diagnosis of immune thrombocytopenia, including secondary forms, and selection of second-line treatment

“…Cytomegalovirus can worsen ITP in patients receiving immunosuppressive treatments because these agents will activate the cytomegalovirus and thus worsen the ITP making it more resistant to treatment. 19 , 20 Helicobacter pylori may “cause” ITP, but only in certain places, e.g., Japan and Italy, is searching for it at diagnosis of ITP routine and is its eradication a uniformly effective approach to ITP. 21 …”