Mechanisms of thrombocytopenia in patients with lymphoproliferative diseases.

Different factors are involved in the development of thrombocytopenia in patients with lymphoproliferative disorders. Significant correlation was detected between the number of megakaryocytes in bone marrow and platelet count (r = 0.485, p = 0.002, n = 37) and significant difference between the number of megakaryocyte in patients with normal platelet count (> 200,000/microliters) and patients with marked thrombocytopenia (platelet count < 100,000/microliters). All patients in the latter group (n = 15) had a relatively low number of megakaryocytes. Low but significant reverse correlation was found between the level of platelet-associated IgG (PA-IgG) and platelet count (r = -0.249, p = 0.024, n = 82) and significant difference between the mean levels of PA-IgG in the groups of patients with platelet count > 200,000/microliters and < 100,000/microliters. PA-IgG were increased in 46% of patients in the total group and in 65% of patients with platelet count < 100,000/microliters. The correlation between platelet count and PA-IgG was about 2 times higher in splenectomized (r = -0.549, p = 0.005, n = 24) than nonsplenectomized patients. All splenectomized patients with platelet count < 100,000/microliters (n = 8) had a significant increase in PA-IgG. Serum antibodies were detected in only 7% of tested patients. This group was characterized by severe thrombocytopenia (in 6 of 10 patients--platelet count < 50,000/microliters) and a high incidence of haemorrhages (in 5 of 10 patients). Thus the depression of platelet production was suggested to be the basic cause of thrombocytopenia in lymphoproliferative disorders. Involvement of immune mechanisms was revealed in a large number of patients and correlated with a deeper and more complicated thrombocytopenia.     

Evidence for an Immunological Pathogenesis of Thrombocytopenia in Chronic Liver Disease

Objectives: To elucidate the roll of platelet-associated IgG (PA-IgG) in the mechanism of thrombocytopenia associated with chronic liver disease. Methods: Platelet count in blood, PA-IgG, and scintigraphic spleen/liver ratio us a marker of splenomegaly was examined in 214 individuals, including 16 controls showing nonspecific reactive change in liver biopsy and 198 patients with chronic liver disease. Results: The mean blood platelet count decreased significantly according to severity of liver disease, from control to liver cirrhosis. PA-IgG levels increased significantly in relation to severity of liver disease, as did spleen/liver ratio. In chronic hepatitis or liver cirrhosis, an inverse correlation was found between platelet counts and PA-IgG levels. An inverse correlation was also observed between platelet count and spleen/liver ratio in liver cirrhosis. The splenic embolization resulted in a significant rise in platelet count and a significant fall in PA-IgG in the 14 cirrhotic patients. Conclusions: These results may give support to evidence for an immunological mechanism mediated by PA-IgG for the thromhocytopenia occurring in chronic liver disease. In the case of liver cirrhosis, this mechanism would act in addition to platelet pooling in the spleen on thrombocytopenia. PA-IgG may also have an important role in thrombocytopenia associated with chronic hepatitis, in which splenic platelet pooling is less marked.     

Glycoprotein V-specific platelet-associated antibodies in thrombocytopenic patients.

In autoimmune thrombocytopenia, platelet-associated IgG (PA-IgG) frequently displays specificity against glycoprotein (GP) IIbIIIa and/or GP IbIX. Because in a high proportion of patients positive PA-IgG may not be explained by these GP specificities, studies on other target proteins are needed. We studied the presence of GP V-specific PA-IgG by direct monoclonal antibody-specific immobilization of platelet antigens (MAIPA) with the monoclonal antibody SW16. We focused on 69 consecutive random patients with histories of thrombocytopenia who were strongly positive for PA-IgG detected by the direct platelet immunofluorescence test (PIFT). PA-IgG against GP V (ratio > or = 1.5) was noted in 15 (22%) patients. The degree of PA-IgG measured by PIFT, and of GP IIbIIIa-and/or GP IbIX-specific PA-IgG measured by direct MAIPA, correlated directly with the GP V-specific PA-IgG (P < 0.001). In one patient, GP V-specific antibodies were associated with quinidine-induced thrombocytopenia. Although this patient had strongly positive GP V-specific PA-IgG, she remained negative in GP IIbIIIa- and GP IbIX-specific direct MAIPA. Two patients studied because of thrombocytopenia associated with gold therapy had strongly positive GP V-specific PA-IgG. In one patient with rheumatoid arthritis and severe gold-induced thrombocytopenia, the amount of GP V-specific PA-IgG decreased during the recovery phase. Thus, GP V may represent an important target antigen in autoimmune-mediated thrombocytopenia, especially in drug-induced thrombocytopenia.     

Liberation of surface and internal platelet-associated IgG (PA-IgG) during platelet activation

The relationship between platelet-associated IgG (PA-IgG) of intact platelets to that of lysed platelets has been studied using a competitive ELISA. In platelets from 20 normal individuals mean surface PA-IgG constituted 35% of mean total PA-IgG and showed a significant linear relationship with total PA-IgG. In platelets from 61 patients with various forms of thrombocytopenia including that with immune causes, 38 showed a similar proportion of PA-IgG on the surface after storage at 2 degrees C, as seen in normal platelets, while in 23, levels of surface and total PA-IgG were equal. Normal platelets activated with thrombin or calcium ionophore A23187, also had levels of surface PA-IgG close to total PA-IgG. Supernatants of platelet suspensions activated with aggregating agents contained increased amounts of IgG and when the platelets were washed, both total and surface PA-IgG were decreased. Liberation of IgG from platelets was slower than that of [14C]serotonin but was decreased by release reaction inhibitors. Platelets treated at 2 degrees C with soluble heat-aggregated IgG, which binds to the Fc gamma receptor, showed increased surface PA-IgG, but, after incubation at 37 degrees C, although [14C]serotonin was released, PA-IgG levels were no longer increased. Thus since platelet activation, including that mediated by IgG binding to the Fc gamma receptor, causes PA-IgG release, levels of both surface-located and total PA-IgG may be affected by platelet activation, either in vivo, or in vitro during sample preparation and assay.     

Mean platelet size related to glycoprotein-specific autoantibodies and platelet-associated IgG

Recent evidence suggests that platelet-associated glycoprotein-specific (GP) antibodies represent true positive autoantibodies and can therefore be taken as the gold standard. Earlier tests, which aimed at detecting platelet-associated IgG (PA-IgG), might have been hampered, e.g. by the variation of platelet size in thrombocytopenic patients. In this study, 206 samples with increased PA-IgG from consecutive thrombocytopenic patients were tested further for GP-specific antibodies with a monoclonal antibody immobilized platelet antigen test (MAIPA) using a combination of a GP IIbIIIa-specific and a GP IbIX-specific antibody for immobilization or, in a separate assay, GP V-specific antibody. Mean platelet size was recorded as forward scatter (FSC) of platelets in flow cytometric analysis of PA-IgG. GP-specific antibodies were detected in 49 (24%) of the 206 patient samples. Their presence correlated well with increased PA-IgG (R = 0.769). The mean platelet size and mean fluorescence intensity (MFI) of PA-IgG were both significantly increased in patients compared with healthy controls (n = 112; P < 0.0001). Notably, PA-IgG was associated with platelet size within the platelet population of both healthy controls and patients (R = 0.999). Further, the probability of GP IIbIIIa and/or IbIX and GP V-specific PA-IgG tended to increase with the mean platelet size of the patients (P = 0.045). In conclusion, large platelets bound more IgG than platelets of normal size, which may explain at least in part the reported low specificity of total PA-IgG measurement. As the PA-IgG displays low specificity compared with the gold standard, its use as such may be abandoned and replaced by tests for platelet-associated GP-specific autoantibodies.     

Use of OKT3 monoclonal antibody as induction therapy for control of rejection in liver transplantation

This report details a single center's experience with OKT3 induction immunosuppression for liver transplantation. One hundred ninety-nine consecutive, unselected adult liver recipients received OKT3 therapy for 9–10 days combined with low-dose steroids and azathioprine. Cyclosporine was begun to overlap with the last few days of OKT3 therapy. The average dose of OKT3 was 45 mg. Fifty-two patients (26.1%) experienced 57 episodes of acute rejection. The median time of onset of rejection was 18 days after grafting. Seventy-eight percent of the rejection episodes were steroid-sensitive. Recurrent rejection was uncommon and the need for OKT3 retreatment was infrequent. One year actuarial graft and patient survival was 79.7% and 82.3% respectively. Based on this evidence, it appears that OKT3 prophylaxis provides good control of acute rejection with a very low incidence of recurrent rejection.     

Platelet associated immunoglobulins in primary biliary cirrhosis: a cause of thrombocytopenia?

Thrombocytopenia in cirrhotic patients is usually attributed to splenic pooling whereas in idiopathic thrombocytopenic purpura it is related to platelet bound immunoglobulin (PA-IgG). Since primary biliary cirrhosis (PBC) is an autoimmune disorder we have undertaken a prospective study to assess the frequency and possible relationship of PA-IgG to thrombocytopenia in this condition. Sixty-two primary biliary cirrhosis patients (28 precirrhotic; 34 cirrhotic) were studied. Twenty-five patients (40%) had raised PA-IgG of whom 18 had cirrhosis. There was a significant inverse correlation between platelet count and PA-IgG (p less than 0.001) and between platelet count and spleen size (p less than 0.001). Thrombocytopenia (platelets less than 100 X 10(9)/l) was found in nine patients (15%); all nine had raised PA-IgG and eight were cirrhotic with an enlarged spleen. Two cirrhotic patients with persistent thrombocytopenia and bleeding episodes were treated with prednisolone and showed a useful therapeutic response. These results suggest that immune mediated platelet destruction and splenic pooling of platelets may both play a part in the thrombocytopenia observed in primary biliary cirrhosis.     

Suspected distinct activation pathways of human lymphocytes induced by antilymphocyte globulin and anti-CD3 monoclonal antibody result in different secretion of hematopoietic colony-stimulating activities.

We evaluated the activation sequence of peripheral blood lymphocytes from healthy donors using different mitogens, including antilymphocyte globulin (ALG), anti-CD3 monoclonal antibody (OKT3), and phytohemagglutinin (PHA). Blood mononuclear cells stimulated by ALG, OKT3 and PHA incorporated 3H-thymidine in the same way. When enriched T cells were tested in the presence of interleukin-1 alpha (0 to 100 U/ml, incorporation of 3H-thymidine was greater in those cells stimulated by ALG than by PHA. OKT3 did not activate enriched T cells. Thymidine incorporation was reduced to less than 50% of maximum concentrations by the addition of 10(-7) mol/1,25-dihydroxyvitamin D3 (vit D3) in PHA- or OKT3-activated cells. However, the inhibitory effect of vit D3 was not apparent in ALG-activated cells. Production of granulocyte-macrophage colony-stimulating factor and interleukin-3 by lymphocytes upon activation was consistently higher when cells were treated with ALG or PHA than with OKT3. Taken together, the data indicate that there appear to be distinct functional mechanisms between ALG- and OKT3-induced lymphocyte activation that lead to characteristic immunohematologic events.     

Platelet-associated IgG in patients with lymphoma

Levels of platelet-associated IgG (PA-IgG) were studied in 72 patients with Hodgkin's (HD) and non-Hodgkin's lymphoma (NHL). Thirty-nine percent of patients with HD and 20% of patients with NHL had elevated PA-IgG levels. There was a positive correlation between disease activity and the presence of PA-IgG in HD and NHL. In patients with HD, PA-IgG strongly correlated with extent of disease and may serve as a marker of disease activity. PA-IgG may have facilitated platelet destruction in 5 of 11 thrombocytopenic patients with HD and increased PA-IgG and in 2 patients with HD and increased PA-IgG who developed severe thrombocytopenia when treated with chemotherapy.     

OKT3 prophylaxis in liver transplantation

In a randomized prospective study of liver transplant recipients, we compared prophylaxis with OKT3, steroids, and azathioprine to cyclosporine, steroids, and azathioprine. Seventy-two percent of patients receiving OKT3 prophylaxis were rejection free in the first 14 days compared to 41% in the cyclosporine group (P=0.02). However, after 14 days through a mean of 6.3 months, the overall incidence of rejection did not differ between the two groups (74% for the cyclosporine group and 48% for the OKT3 group). There was no increase in the rate of infectious complications noted in the OKT3-treated group. Thirty-nine percent of the OKT3-treated patients developed anti-OKT3 antibodies. Eight patients in the OKT3 group required reuse of OKT3 for rejection. Six of these continued to have greater than 10% CD3-positive cells with retreatment. Five were rescued successfully. With a mean survival of greater than 674±209 days in the OKT3-treated group and 626±242 days in the cyclosporine-treated group, no overall differences in graft and patient survival, liver function, renal function, late rejection incidence, or infectious complications were evident between the two groups. We conclude that OKT3 offers no long-term benefit compared to cyclosporine prophylaxis and should be reserved for treatment of rejection in patients in whom cyclosporine may be contraindicated.     

Immune thrombocytopenia: effects of maternal gamma globulin infusion on maternal and fetal serum, platelet, and monocyte IgG

A 24-year-old woman with lupus-like serologic abnormalities had immune thrombocytopenia that resolved after splenectomy, but increased quantities of platelet surface IgG persisted. Three years later, during the 36th week of her first pregnancy, gamma globulin (400 mg/kg daily for 5 days) was administered intravenously to decrease the risk and/or severity of immune thrombocytopenia in her infant. The infusion produced marked but transient elevations of maternal concentrations of serum IgG and quantities of monocyte surface IgG, but no significant changes in Fc receptor-mediated rosetting of peripheral blood monocytes with antibody-sensitized platelets occurred. Modest increases in quantities of platelets and plasma platelet-specific IgG were demonstrated. The infant, delivered by cesarean section 2 days after the end of the infusion, had a normal platelet count; cord blood had a normal concentration of serum IgG, but an elevated quantity of platelet surface IgG (by comparison with values for normal adults). Infant values of plasma platelet-specific IgG, monocyte surface IgG, and monocyte/platelet rosettes also were within the range of normal for adults. Anticytomegalovirus antibody was present in large amounts in the gamma globulin infused, first appeared in maternal serum after therapy, and was detected in cord serum. The significance of these observations to the management of immune neonatal thrombocytopenia is discussed.     

Genetic polymorphism H131R of Fcγ receptor type IIA (FcγRIIA) in a healthy Finnish population and in patients with or without platelet-associated IgG

Abstract: Patients (n = 113) with histories of thrombocytopenia and with different profiles for platelet-associated IgG (PA-IgG) were subdivided according to the genetic polymorphism H131R in the Fcγ receptor type IIA (FcγRIIA). PA-IgG was measured by the direct platelet immunofluorescence test (PIFT), and GP IIbIIIa and/or GP Ib-specific PA-IgG was investigated by a modified version of the direct monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay. As a control, the distribution of FcγRIIA polymorphism H131R was determined among 93 healthy Finnish blood donors. The frequencies for H131 and R131 were 0.56 and 0.44 (CI: 0.37–0.51), respectively, which did not differ significantly from those in other Caucasian populations. The distribution of the genotypes HH131, HR131 and RR131 in the patients and controls did not differ significantly. In the HH131 group, the PA-IgG was higher than in the RR131 group (p = 0.082). Female patients with the genotype RR131 seemed to be younger than those with HH131 (p = 0.065). Among the female patients, a significantly greater number were under 40 yr old in the RR131 group than in the HH131 group (p = 0.0060). Within the RR131 group, the female patients were far younger than the male patients (median 29 vs. 61 yr; p = 0.0021). The results point to the heterogeneity of immune thrombocytopenia, which may partly explain the poor predictive value of PA-IgG studies.     

Platelet-Associated IgG in Thrombocytopenia: A Comparison of Two Techniques

The results obtained in the analysis of 130 thrombocytopenic patients with a radioimmunoassay (RIA) for platelet-associated IgG (PA-IgG) and the platelet suspension immunofluorescence test (PIFT) were compared. The RIA was positive in 33 of 41 (82.9%) patients with idiopathic thrombocytopenia (ITP) and in 51 of 79 (64.4%) patients with secondary thrombocytopenia (STP). The PIFT was positive in 37 of the 41 (90.2%) ITP patients and in 57 of the 79 (72.2%) STP patients. Sensitivity and specificity for the diagnosis of ITP of both tests were comparable: 82.9 and 40.9% for the PA-IgG(RIA) and 90.2 and 36.7% for the PIFT. A significant positive correlation was observed between the mean amount of PA-IgG measured and the height of PIFT scores with anti-IgG. Of 38 discrepancies between PA-IgG(RIA) and PIFT with anti-IgG, 15 were due to borderline results, 17 were associated with abnormal platelet-size distribution and 20 were associated with occurrence of IgM antibodies. These results suggest influences of platelet fragments and/or aggregates on accurate measurement of PA-IgG. Both fragments and aggregates escape from accurate platelet counting, while their contribution to the total IgG content remains. Therefore, a falsely elevated PA-IgG (RIA) may be measured.     

IgG-associated immune thrombocytopenia in Waldenstr?m macroglobulinemia

Waldenstr?m macroglobulinemia (WM) is characterized by serum IgM monoclonal gammopathy, and only occasionally complicated by immune thrombocytopenia. Rarely, coexistence of non-IgM gammopathy in WM has been reported. Herein, we describe an 81-year-old case of WM with rapidly progressive immune thrombocytopenia accompanied by concurrent IgG gammopathy and elevation of platelet-associated IgG (PA-IgG). Immunostaining of the bone marrow specimen displayed not only IgM positive but also IgG positive plasmacytoid cells. Although dexamethasone therapy had no effect on thrombocytopenia, a modified RCD regimen (rituximab 375 mg/m² i.v. day 1, cyclophosphamide 375 mg/m² i.v. day 2 and dexamethasone 12 mg/body orally days 1–7) successfully normalized PA-IgG as well as IgG and IgM paraproteinemia and significantly increased platelet count. The current case suggests that the IgG gammopathy associated with WM is likely to be an etiology of immune thrombocytopenia and that tumor reduction, rather than immunosuppression, leads to an improvement of concurrent thrombocytopenia.     

Quantification of Platelet-Bound Alloantibodies by Radioimmunoassay: A Study on Some Variables

Several variables that may affect accurate measurement of platelet-associated IgG (PA-IgG) were studied using a radioimmunoassay of the consumption type. The amount of PA-IgG of washed, unfixed normal donor platelets was 1.0 +/- 0.9 fg IgG/platelet (mean +/- 2 SD). Upon storage of washed platelets in a buffer containing EDTA, the amount decreased significantly to 0.2 +/- 0.2 fg IgG/platelet. Simultaneously, an increase in modal platelet volume was observed. Similar results were obtained when platelets were fixed with paraformaldehyde (PFA). We postulate that this decrease in PA-IgG is caused by the release of plasma IgG entrapped by the surface-connected canicular system of the platelet, when the platelets swell during storage in EDTA or fixation with PFA. This presence of varying amounts of entrapped plasma IgG may cause the wide discrepancies in PA-IgG found in normal donor platelets as well as platelets from ITP patients by other investigators. A good quantification of platelet-bound alloantibodies was possible with our assay when platelets were routinely fixed to diminish the amount of nonspecific PA-IgG. This was demonstrated with different anti-Zwa (= anti-PlA1), anti-Baka and anti-HLA sera. We also observed that fragments of platelets as well as fragments of cells of other types can cause aspecifically increased Pa-IgG values and can thus interfere with the proper measurement of platelet-bound antibodies in all kinds of immunoassays in general.     

Circulating antiplatelet antibodies in pregnant women with immune thrombocytopenic purpura as predictors of thrombocytopenia in the newborns

Newborns from mothers with immune thrombocytopenic purpura (ITP) have a risk of thrombocytopenia due to passage of maternal antiplatelet antibodies into fetal/neonatal circulation. We looked for predictors of neonatal thrombocytopenia (nTP) in pregnant women with ITP. One hundred pregnant women with platelet count <100 × 10⁹/l, no non-immune causes of thrombocytopenia and increased platelet associated IgG (PA-IgG) were included in the study. Thirty seven and 63 of them gave birth to babies with and without nTP, respectively (nTP+ and nTP? groups). Platelet count, mean platelet volume, PA-IgG, antiplatelet circulating antibodies (cAB), time of ITP onset (before or during pregnancy), and frequency of corticosteroid treatment were compared in these groups. There were no differences in all test parameters between nTP+ and nTP? groups except cAB. These antibodies were detected in 33 out of 37 in nTP+ group and in 2 out of 63 mothers in nTP? group (p < 0.001). The sensitivity of this test was 89% and its specificity was 97%. A strong reverse correlation (r = ?0.749, p < 0.001) was established between maternal cAB titer and neonatal platelet count. Antibodies against glycoproteins IIb–IIIa and/or Ib were identified in antigen specific MAIPA (Monoclonal Antibody Immobilization of Platelet Antigen) assay only in 10 out of 19 (53%) test sera with cAB. Antiplatelet cAB in pregnant women with ITP could serve as reliable predictors of nTP in their babies.     

High-dose intravenous IgG for chronic idiopathic thrombocytopenic purpura in adults

Summary Sixteen adult patients of mean age 48 years with chronic ITP were studied for platelet response to high-dose (0.4 g/kg body weight per day for five consecutive days) intravenous polyvalent intact IgG in the absence of any concurrent treatment. The platelet count returned to normal values in nine patients, a partial response (rise in the platelet count between 50 and 150 ×10⁹/l) was observed in three cases. One patient refractory to any other treatment went into a sustained remission. In the other responsive patients the response was only transient. Among seven splenectomised patients only three responded to IgG infusions versus nine in the non-splenectomised group. The length of ITP history appeared as a more critical factor for the response to IgG than previous splenectomy.     

MACULAR HAEMORRHAGE IN ADULT ACUTE LEUKAEMIA PATIENTS AT PRESENTATION AND THE RISK OF SUBSEQUENT INTRACRANIAL HAEMORRHAGE

Glycoprotein (GP)-specific platelet-associated IgG (PA-IgG) may be demonstrable in autoimmune-mediated thrombocytopenia. We studied 159 consecutive patients with histories of thrombocytopenia by a modified direct monoclonal antibody-specific immobilization of platelet antigens (direct MAIPA) assay, which immobilizes GP IIb/IIIa, GP Ib/IX and GP Ia/IIa simultaneously. This modification requires smaller quantities of platelets than standard measurements performed separately. PA-IgG was present in 84/159 (53%) patients, as shown by the direct platelet immunofluorescence test (PIFT) with flow cytometry as a reference. PA-IgG against GP IIb/IIIa and/or GP Ib/IX and/or GP Ia/IIa was noted in 46 patients (29%), of whom 93% (43/46) were also PA-IgG positive. The amount of PA-IgG detected by PIFT correlated directly with that detected by direct MAIPA ( r =0.71; P <0.0001). Only three patients 12548 with negative direct PIFT had GP-specific PA-IgG. GPV-specific PA-IgG was detected in 13 (10%) of the 125 patients, in whom further studies could be performed. In the subgroup of patients with GP-specific PA-IgG, the median fluorescence intensities of direct PIFT were higher than in patients with no GP-specific PA-IgG ( P <0.001). Direct PIFT and direct MAIPA divided the patients into asymmetric subgroups. However, the relative roles of these tests in the diagnosis of autoimmune-mediated thrombocytopenia await further studies.     

Slow infusion of vincristine in the treatment of idiopathic thrombocytopenic purpura

Ten patients with idiopathic thrombocytopenic purpura (ITP) were treated with vincristine (VCR), given as a slow infusion over a 4-hr period, at weekly intervals for 4 weeks. The VCR therapy achieved a sustained recovery of platelet count in five patients with ITP of 2 weeks to 5 months duration; a transient recovery was observed in four patients with ITP of 6 months to 5 years duration. Therapy had no effect at all in one patient who had ITP of 10 years duration. Vincristine therapy appears to be therapeutically more beneficial when given as a slow infusion and can achieve sustained recovery of platelet count in patients with ITP of less than six months duration.     

Use of high-dose intravenous immunoglobulin in systemic lupus erythematosus: report of three cases

Three patients with life-threatening manifestations of systemic lupus erythematosus (SLE), unresponsive to conventional high-dose corticosteroid and/or immunosuppressive therapy were treated with intravenous polyspecific IgG (IVIG). Following IVIG infusion, lupus encephalitis in the first patient quickly resolved and the impressive improvement of the clinical status was associated with a transient increase in C1q-binding activity. The daily infusion of IgG had to be suspended after three days in the second patient with encephalitis and nephritis, because the renal function rapidly deteriorated; subsequently, six plasma exchanges led to an almost complete recovery. Finally, leukocyte and platelet counts increased and remained within normal range following IgG therapy in the third patient having SLE-associated leuko- and thrombocytopenia. In all three patients a decrease in anti-DNA antibody levels and an increase in total complement hemolytic activity were detected after therapy.