# An Unusual Cause of Secondary ITP in a 34-Year-Old Hispanic Male

Authors: Ayrton Bangolo; Mohamed Ahmed; Ali Atoot; Ashraf Mahmoud; Chibuzo Agbakwuru-Onyike; Maria Karina Larni Y. Palad; Michael Sciarra; Adam Atoot
Journal: Case Reports in Hematology
 (2021)

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## Abstract

Secondary immune thrombocytopenic purpura (ITP) associated withHelicobacter pylori (H. pylori) infection has been described in the literature. It appears to have a geographic distribution; mostly encountered in countries with a higher prevalence for H. pylori such as Italy or Japan. H. pylori eradication has been recommended in the management of ITP with studies showing improvement in the platelet count in some patients. Substantial platelet count increases in patients with severe thrombocytopenia (platelet counts <30 × 103 microliter), however, are uncommon with H. pylori treatment alone. Here, we present a 34-year-old Hispanic male with worsening chronic thrombocytopenia that resolved following eradication of his H. pylori infection. Herein, we highlight a rare and reversible cause of secondary ITP. With this case report, we hope to encourage physicians to include H. pylori testing in the evaluation of thrombocytopenia.


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## Body

## 1. Introduction

Immune thrombocytopenic purpura (ITP) is an acquired disorder in which there is immune-mediated destruction of platelets with possible inhibition of platelet release from the megakaryocytes [1]. In adults, it is a more chronic disease; however, some will experience spontaneous remission which will usually occur within months of the initial diagnosis. ITP is considered secondary if it is associated with an underlying disorder [1]. Several studies have recently shown improvement in platelet counts after eradicating Helicobacter pylori (H. pylori) infection which suggests an association between the two conditions [2]. It appears that response rates are higher in countries where H. pylori infection is endemic and in patients with milder degrees of thrombocytopenia [3, 4]. Herein, we present a 34-year-old male with ITP and worsening platelet levels who was found to have H. pylori infection. Following treatment of his infection, the patient had significant improvement and normalization of his platelet count. With this case report, we aim to encourage clinicians to include H. pylori in the differential diagnosis of ITP.


## 2. Case Presentation

This is a 34-year-old Hispanic male with no significant past medical history who presented to the clinic for evaluation of a gnawing, moderate, intermittent epigastric pain that started 3-4 months prior to the visit. The pain improves with meals and is associated with reflux and early satiety. Notably, the patient was told he had “low platelets” on his annual physical the year prior to our encounter. He denied any diarrhea, nausea, vomiting, spontaneous bruising, epistaxis, or gingival bleeding. He also denied any intravenous drug use or any dangerous sexual behaviors. He has never been hospitalized and did not undergo any surgical procedures in the past. The family history was noncontributory.Physical examination was significant for epigastric tenderness on palpation but was otherwise unremarkable. Laboratory results revealed a positive urea breath test as well as worsening thrombocytopenia with a platelet count of 50 × 103 microliter (uL) (150–450 × 103) from a platelet count of 91 × 103 uL the year prior as shown in Table 1. The remainder of the laboratory evaluation, including a complete blood count, lipid profile, and urinalysis was unremarkable. The abdominal ultrasound was unremarkable except for a trace effusion between the liver and diaphragm. Further evaluation with a noncontrast computed tomography (CT) of the abdomen/pelvis showed no abdominal pathology.Table 1
Laboratory values.
Laboratory valuesWhite blood cells5.5 × 10∗3 (3.4–10.8 × 10∗3) microliter (uL)Red blood cells5.0 × 10∗6 (4.14–5.80 × 10∗6) uLPlatelet count on admission50 × 10∗3 (150–450 × 10∗3) uLPlatelet count a year ago91 × 10∗3 (150–450 × 10∗3) uLPlatelet count 1 week into therapy105 × 10∗3 (150–450 × 10∗3) uLPlatelet count 5 weeks after triple therapy178 × 10∗3 (150–450 × 10∗3) uLErythrocyte sedimentation rate3 (0–15) millimeter per hour (mm/hr)C-reactive protein<1 (0–10) milligram per liter (mg/L)Hepatitis B surface antigenNegativeHepatitis B surface antibody, quantitative>10,000 (immunity >9.9) milli-international units per milliliter (mIU/mL)Aspartate aminotransferase19 (0–40) international units per liter (IU/L)Alanine transaminase25 (0–44) IU/LHuman immunodeficiency virus antigen/antibody 4th generationNonreactiveHepatitis C antibody<0.1 (0.0–0.9) signal-to-cutoff ratio (s/co ro)Antinuclear antibodyNegativeSerotonin release assayNegativeThe patient was started on a 10-day regimen triple therapy (amoxicillin, clarithromycin, and lansoprazole) for eradication ofHelicobacter pylori (H. pylori). One week after initiation of therapy, repeat laboratory results revealed significantly improved platelet levels, 105 × 103 uL. Additional workup for thrombocytopenia was ordered including a hepatitis panel, human immunodeficiency virus testing, heparin-induced thrombocytopenia antibodies, and a serotonin release assay which were all within normal limits.The patient was reevaluated 5 weeks after completion of the triple therapy. He reported complete resolution of his abdominal pain. The urea breath test was negative as well as the stool antigen forH. pylori. The laboratory results revealed continuous improvement and normalization of the platelet levels, 178 × 103 uL.


## 3. Discussion

Immune thrombocytopenia (ITP, also called idiopathic thrombocytopenic purpura or immune thrombocytopenic purpura) is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. It is one of the more common causes of thrombocytopenia in otherwise asymptomatic adults [1]. ITP is termed secondary if it is associated with an underlying disorder; autoimmune disorders, particularly systemic lupus erythematosus (SLE), and infections, such as human immunodeficiency virus (HIV) infections and hepatitis C, are also common causes. The association of ITP with Helicobacter pylori (H. pylori) infection is unclear [1]. Some studies show that eradication of H. pylori with antibiotics result in marked platelet count increases in patients with ITP [3]. Patients with acute H. pylori are often asymptomatic or develop mild self-limited dyspeptic symptoms and may not seek medical attention and thus are not immediately investigated [5]. Our patient had a one-year history of acquired unexplained thrombocytopenia and developed dyspeptic symptoms overtime. He was not initially worked up for H. pylori a year prior to our encounter, given the lack of dyspeptic symptoms at the time. He did not endorse any signs or symptoms related to thrombocytopenia. The patient also denied any personal or family history of bleeding disorders or autoimmune conditions.ITP is a diagnosis of exclusion which is made in patients with isolated thrombocytopenia. The diagnosis of ITP requires that other potential causes of thrombocytopenia, such as recent infections, medications, rheumatologic disorders, or liver disease, be excluded [6]. Several guidelines recommend obtaining a peripheral blood smear to confirm that thrombocytopenia is not artifactual due to platelet clumping and HIV and hepatitis C testing [6–8]. Testing for H. pylori is appropriate in patients with gastrointestinal symptoms suggestive of infection because of a reported association between ITP and H. pylori infection. Routine screening for H. pylori may be reasonable in asymptomatic individuals as well [4]. Antiplatelet antibody testing has low sensitivity and is not recommended [9]. Our patient was not taking any medications including any herbal supplementation to explain his findings. He had no history of rheumatologic disorders, and the liver function test was unremarkable. A year prior to our encounter, the patient had unexplained thrombocytopenia but did not have any gastrointestinal symptoms. It was his dyspepsia and early satiety a year later that prompted evaluation for H. pylori infection. However, even despite the lack of dyspeptic symptoms, the patient should have been evaluated for H. pylori as part of the workup of unexplained thrombocytopenia.The treatment of ITP uses drugs that decrease reticuloendothelial uptake of the antibody-bound platelet, decrease antibody production, and/or increase platelet production. Patients with platelet counts >30 × 103 μL appear not to have increased mortality related to the thrombocytopenia and usually do not require treatment with intravenous immune globulin (IVIG) or corticosteroids [1]. IVIG or corticosteroids are usually reserved for bleeding, elective surgery, or severe thrombocytopenia (<30 × 103 microliter) without bleeding [10]. A systematic review of the English literature concluded that, in secondary ITP, there is improvement of thrombocytopenia with H. pylori eradication [4]. Our patient had a platelet level above 30 × 103 uL, was not bleeding, and was not scheduled for any surgeries. Thus, he was not treated with corticosteroids or IVIG. He was found to have a positive urea breath test and was initiated on triple therapy for H. pylori eradication. Following H. pylori eradication, the platelet levels normalized, an outcome that is consistent with findings in the literature.


## 4. Conclusion

Immune thrombocytopenic purpura (ITP) is an acquired disorder that can be associated withHelicobacter pylori (H. pylori) as previously reported in the literature. H. pylori eradication has been associated with improvement and normalization of the platelet levels, especially in patients with nonsevere thrombocytopenia. With this case report, we hope to contribute to the growing literature of H. pylori associated with ITP. This case report has the objective to encourage clinicians to include H. pylori in the workup of unexplained thrombocytopenia, even without gastrointestinal symptoms.



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