False-negative findings in chorionic villus sampling. An experimental approach and review of the literature

61 fetuses/newborns who had an aberrant karyotype in amniocentesis (AC) or percutaneous umbilical blood sampling (PUBS) were followed-up by chorionic villus sampling (CVS) at birth or after interruption. The overall rate of discrepancies is surprisingly high. Among 46 cases with a non-mosaic numerical aberration an AC or PUBS three had a discrepant finding in placental tissue. This was also true in one of seven cases with non-mosaic structural aberrations and in three of five cases with mosaic structural aberrations. All three cases with a mosaic numerical aberration in AC or PUBS were not represented by CVS and/or lymphocytes or fibroblasts, demonstrating the general problem of the unpredictable prognostic value of mosaicism. Our data suggest, that in case of prenatal diagnosis by CVS, using a combined procedure of short-term (STC) and long-term culture (LTC), in our sample we would have missed one case of 45,X (1.6 per cent). When relying only on STC another two cases, one with 47, +21 and one with 46,XX,der(22) would not have been recognized (4.9 per cent, n = 3). All other chromosome aberrations would have been detected by STC alone. On the other hand, one case of 45,X was 'nearly missed' because of low-grade mosaicism in AC (45,X[1]/46,XX[19]), whereas in placental tissues and PUBS only 45,X was represented. This study mimics a false-negative rate of about 1:3000 (STC plus LTC) or about 1:1000 (STC alone) for an a priori risk group of two per cent (e.g., advanced maternal age).     

Study on purple pigmentation in five cases with purple urine bag syndrome

We reported five patients with purple urine bag syndrome (PUBS). Four patients had indicanuria, and, in three of them, purple pigmentation was reproduced by inoculating urinary isolates, in the broth with indoxyl sulfate. Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterococcus avium were considered to produce the purple pigment in three patients. However, attempts to reproduce the purple pigment failed in two patients, and one of them did not have indicanuria. These results suggest that indicanuria is not necessarily required for the development of PUBS.     

Pregnancy and labor in idiopathic thrombocytopenic purpura

Clinical data from eight pregnant women with idiopathic thrombocytopenic purpura (ITP) were retrospectively analyses. The mean age of the women was 28.2 years. Five women underwent splenectomy during childhood. The lowest maternal platelet count observed ranged from 8000 to 88000/mm3. Genital bleeding occurred in only one case. Treatment was based on administration of corticosteroids with or without human-pooled immunoglobulins. Caesarian section was performed in all cases. Six newborns were healthy and had a successful subsequent course. Two infants died, one in utero because of abruptio placentae and the other one 1 month post partum because of a cerebral haematoma. After a mean follow-up of eighteen months, thrombocytopenia is still present in two women, despite the continuous treatment. In conclusion, ITP rather rarely coincides with pregnancy. Treatment is usually successful for the mother but the risk for the fetus remains considerably high.     

Coupling protein stability and protein function in Escherichia coli CspA

Idiopathic thrombocytopenic purpura (ITP, also known as immune thrombocytopenic purpura) in adults is principally a disease of young women. Although in some patients the onset is acute and complete resolution occurs, in most patients, the onset is insidious and the course is chronic. In spite of the relative frequency of ITP, there are important unresolved issues in its diagnosis and management. For this reason, the American Society of Hematology (ASH) chose ITP as the disease topic for its initial sponsored practice guideline in 1993. A major conclusion of the published guideline was the lack of firm evidence on which to base diagnostic procedures and management strategies. This review describes the clinical features of ITP in adults, emphasizes the principal unresolved issues in diagnosis and management, and outlines the critical areas for future research.     

Trends in rates of occupational fatal injuries in the United States (1983-92)

Recent advancements in laparoscopic surgery have made laparoscopic splenectomy possible. We retrospectively compared the outcomes of laparoscopic versus open splenectomy in patients with idiopathic thrombocytopenic purpura (ITP) or beta-thalassemia. From July 1993 to July 1997, 52 patients (ITP, 43 cases; beta-thalassemia, 9 cases) underwent either laparoscopic (30 patients, 9 men, 21 women; average age, 36.9 years) or conventional open splenectomy (22 patients, 5 men, 17 women; average age, 34.3 years). The two groups were similar in terms of sex, age, diagnosis, duration of disease, preoperative platelet count, and spleen size. The mean surgical time, estimated amount of blood loss, duration of postoperative recovery, analgesic usage, and complications were compared between the two groups. Laparoscopic splenectomy was successful in 29 (97%) of the 30 patients. The mean surgical time in the laparoscopy group was longer than in the open splenectomy group (190.6 vs 113.9 minutes, p < 0.01). The laparoscopy group had earlier postoperative oral intake (15.2 vs 52.6 hours, p < 0.01), less usage of analgesics (meperidine 50 mg/unit, 1.1 vs 2.8 units, p < 0.01) and a shorter postoperative hospital stay (4.1 vs 6.8 days, p < 0.01). The estimated blood loss, incidence of accessory spleen, surgical complication rate, and recurrence rate of thrombocytopenia were similar in the two groups. Our findings show that laparoscopic splenectomy in patients with ITP or beta-thalassemia is as safe as the open approach. While laparoscopy required a longer surgical time, the recovery period was shorter, analgesic use was less, and physical discomfort was less severe.     

On a possible mechanism of energy conservation in sarcoplasmic reticulum membrane

The activation of ATP equilibrium Pi exchange, ITP equilibrium Pi exchange, and the degree of phosphorylation of the membrane of sarcoplasmic reticulum vesicles by ATP, ITP, and Pi were compared under different experimental conditions. In media containing 0.1 mM CaCl2, 6 mM Pi, and 4 mM ATP, during the period of Ca2+ accumulation the rate of ATP equilibrium Pi exchange was very low and the level of membrane phosphorylation by ATP was about 10-fold higher than the level of membrane phosphorylation by Pi. When net Ca2+ accumulation ceased and the Ca2+ concentration of the assay media had fallen to less than 5 muM, the degree of membrane phosphorylation by ATP decreased 4-fold and both the level of membrane phosphorylation by Pi and the rate of ATP equilibrium Pi exchange increase 4- to 6-fold. Contrasting with these data, when ATP was replaced by ITP, the rate of ITP equilibrium Pi exchange and the level of membrane phosphorylation by Pi were already high during the period of Ca2+ accumulation and varied slightly when the Ca2+ concentration of the incubation medium decreased to less than 5 muM. During the period of Ca2+ accumulation, the degree of membrane phosphorylation by Pi varied inversely with the NTP or NDP concentration of the medium, ATP and ADP being more effective than ITP and IDP in inhibiting the membrnae phosphorylation by Pi. Leaky vesicles incubated in media containing a high Ca2+ concentration were still able to catalyze both ATP equilibrium Pi and ITP equilibrium Pi exchange. Although the membrane of leaky vesicle was amply phosphorylated by Pi in media containing 0.1 nM CaCl2 and ITP, a significant rate of ITP equilibrium Pi exchange could only be measured in Ca2+ concentrations higher than 0.5 mM. The Ca2+ concentration required for half-maximal activation of the rate of either ITP equilibrium Pi or ATP equilibrium Pi exchange in leaky vesicles was found to be in the range of 1 to 2 mM. In leaky vesicles, the apparent Km of Pi for the ITP equilibrium Pi exchange was at least 1 order of magnitude lower than for the ATP equilibrium Pi exchange.     

Partial complement deficiencies in idiopathic thrombocytopenia of childhood

We have examined the classical complement activation pathway in 36 children with idiopathic thrombocytopenia (ITP) in a retrospective study. An increased prevalence of congenital, partial complement deficiencies is found in ITP. Homozygous C4A deficiency was found in 5 patients (p < 0.05) and heterozygous C2 deficiency in 2 other patients (p = 0.05). We suggest that some cases of childhood ITP belong to the immune complex mediated diseases, such as systemic lupus erythematosus and that abnormal immune complex formation and clearance may lead to ITP.     

Relationships between nucleoside triphosphate pyrophosphohydrolase activity and inosine triphosphate accumulation in human erythrocytes

The relationship between nucleoside triphosphate pyrophosphohydrolast (NTPH) (EC 3.6.1.19) activity in erythrocyte lysates and accumulation of radioactive inosine triphosphate (ITP) in human erythrocytes incubated in vitro with [14C]hypoxanthine, was studied in 93 humans. When ITP accumulation, expressed as percentage of total radioactive nucleotides, was plotted against NTPH specific activity, an inverse relationship was found to exist. A continous spectrum of NTPH specific activities and ITP accumulation values exists in the human population and the relationship between these two parameters follows the relationship of substrate concentration to enzyme activity predicted by Michaelis-Menten enzyme kinetics. One interpretation of these data is that the ITP concentration in human red blood cells is controlled by the degradation of ITP to IMP and pyrophosphate catalyzed by NTPH.     

Immune thrombocytopenic purpura in three patients with preexisting ulcerative colitis

Ulcerative colitis (UC) is associated with extraintestinal diseases in numerous target tissues. Associated immune-mediated hematological diseases, however, are rarely described. We report three Caucasian adult patients with UC and immune thrombocytopenic purpura (ITP). Platelet-associated antibodies (IgG) were positive in two patients, and bone marrow examinations in two patients revealed normal to increased megakaryocyte numbers. ITP was treated with corticosteroids in all patients. Two patients eventually received intravenous immune gamma-globulin, and one patient required surgical splenectomy. Of particular interest, UC preceded the onset of ITP in all patients (by from 1 to 19 yr). This suggests that ITP in these patients is causally associated with UC, possibly secondary to immunostimulation from lumenal antigens and altered immunoregulation.     

Autoreactive T cells to platelet GPIIb-IIIa in immune thrombocytopenic purpura. Role in production of anti-platelet autoantibody

T cell proliferative responses to platelet membrane GPIIb-IIIa were examined in 14 patients with chronic immune thrombocytopenic purpura (ITP), 7 systemic lupus erythematosus (SLE) patients with or without thrombocytopenia, and 10 healthy donors. Although peripheral blood T cells from all subjects failed to respond to the protein complex in its native state, reduced GPIIb-IIIa stimulated T cells from three ITP patients and one SLE patient with thrombocytopenia, and tryptic peptides of GPIIb-IIIa stimulated T cells from nearly all subjects. The specificity of the responses for GPIIb-IIIa was confirmed by activation of GPIIb-IIIa-primed T cells by a recombinant GPIIbalpha fragment in secondary cultures. Characterization of T cell response induced by modified GPIIb-IIIa showed that the response was restricted by HLA-DR, the responding T cells had a CD4(+) phenotype, and the proliferation was accelerated only in ITP patients, suggesting in vivo activation of these T cells. In vitro IgG anti-GPIIb-IIIa synthesis in PBMC cultures was induced by modified GPIIb-IIIa specifically in ITP patients with platelet-associated anti-GPIIb-IIIa antibody. Anti-GPIIb-IIIa antibody produced in supernatants was absorbed by incubation with normal platelets. In summary, CD4(+) and HLA-DR-restricted T cells to GPIIb-IIIa are involved in production of anti-platelet autoantibody in ITP patients and are related to the pathogenic process in chronic ITP.     

Feasibility of a rapid method to evaluate platelet survival time

The purpose of this study was to evaluate the feasibility of a shorter method of performing platelet kinetic studies with respect to the conventional 8-9-day approach. METHODS: We studied 41 patients (28 women, 13 men; mean age 52 yr) with primary idiopathic thombocytopenic purpura (ITP) (n = 20), secondary ITP (n = 9), HCV associated thrombocytopenia (n = 9), splenectomy (n = 1) and hairy-cell leukemia (n = 1). The patients were in a steady-state of platelet turnover. Initial platelet counts ranged from 19 to 302 x 10(9)/liter (mean value = 83). Platelet survival times (PST) were measured from the blood radioactivity disappearance curve of 111In-oxine-labeled autologus platelets following the recommendations of the International Committee for Standardization in Haematology: blood samples were taken at 30 min and 2 and 4 hr and thereafter daily for 7 days. PST was calculated by the weighted mean method and ranged from 18 to 219 hr (mean value = 98). PST was also calculated using only the data collected at 2, 48 and 96 hr. If the radioactivity in the blood at 96 hr exceeded 10% of the 2-hr value, the additional point at 168 hr was used. RESULTS: By using this reduced dataset, we obtained a correlation of r = 0.97 with the PST obtained from the whole dataset. In 24 patients, the difference was between +/- 10 hr and exceeded 1 day in only 4. CONCLUSION: About 94% of the data may be recovered with only three or four blood samples and the duration may be shortened to 4 days in a significant proportion of patients (48% of ITP patients). This approach offers the advantages of increased patient throughput, compliance and reduced examination costs.     

A case of adult idiopathic thrombocytopenic purpura associated with atypical mumps virus infection

A 30-year-old male admitted to out hospital complaing of petechiae. He had attack of fever 2 days before admission, without parotitis and orchitis. Laboratory data showed marked thrombocytopenia. Bone marrow showed normocellularity with an increase of megakaryocytes. Antimumps IgM was positive by the EIA. He was diagnosed as idiopathic thrombocytopenic purpura (ITP) associated with mumps virus infection. After the administration of oral prednisolone and 5 days-infusion of gamma-globulin, platelet count increased rapidly. Prednisolone discontinued within 35 days, as in acute ITP, and he maintained remission. In conclusion, the test for antiviral antibodies is indispensable to exclude acute ITP in adult ITP patients.     

Primary biliary cirrhosis associated with idiopathic thrombocytopenic purpura

A case of primary biliary cirrhosis (PBC) associated with idiopathic thrombocytopenic purpura (ITP) is reported. The patient is a 59-year-old man. When he was 49 years old, he was diagnosed with ITP and received steroid therapy that successfully increased platelet numbers. However, the steroid therapy failed to normalize the elevated gamma-glutamyl transpeptidase. Ten years after this episode, he suffered from general itching and malaise and exhibited a gradual increase of serum biliary enzyme levels. Immunologically, IgM was increased and anti-mitochondrial antibody was positive. Histological findings of liver needle biopsy showed chronic non-suppurative destructive cholangitis, confirming the diagnosis of PBC. To date, very few PBC cases associated with ITP have been reported. Our case is the second one in Japan. PBC and ITP in our patient seemed to develop simultaneously, but the effect of steroid therapy on the two conditions was different. This result suggests that the autoimmune process may have been different in PBC and ITP in the present patient.     

Special imaging casebook. Nager''s syndrome

Idiopathic thrombocytopenic purpura (ITP) is refractory to initial treatment (steroids and splenectomy) in 25 to 30% of patients. These patients have a significant risk of fatal hemorrhage. Two patients with ITP refractory to multiple interventions and severe depression of platelet counts responded to treatment with liposomal doxorubicin with a return of platelet counts to normal. The drug is easily administered and was well tolerated. Use of this drug in refractory ITP merits further study.     

Fibrinogen/fibrin degradation products in serum of patients with idiopathic thrombocytopenic purpura: elevated levels during severe thrombocytopenic phase of the disease

Sera from 23 patients with idiopathic thrombocytopenic purpura (ITP), 14 patients with aplastic anemia with severe thrombocytopenia and healthy control subjects were tested for the presence of fibrinogen/fibrin degradation products (FDP), using the tanned red cell hemagglutination inhibition immunoaassay. The concentrations of circulating FDP of ITP patients (mean 12.01 mug/ml) were significantly higher than those of the patients with aplastic anemia (mean 4.01 mug/ml, p less than 0.05) or normal controls (mean 3.10 mug/ml, p less than 0.001). The patients with untreated ITP with very low platelet counts had higher levels of FDP than those of the treated group (p less than 0.01). Serum FDP and a battery of other coagulation-fibrinolysis tests were serially carried out over a period of 10 weeks in two patients with ITP. The initially high FDP promptly decreased as circulating platelets increased in response to steroid in both patients, while plasma fibrinogen, euglobulin lysis time, prothrombin time and partial thromboplastin time remained essentially normal during the course of observation. The exact source of the increased serum FDP in ITP was not established, but a few possible mechanisms responsible for this abnormality were discussed.     

Platelet dysfunction associated with immune-mediated thrombocytopenia in dogs

The effect of antiplatelet antibody on in vitro platelet function was investigated in 15 dogs with immune-mediated thrombocytopenia (ITP). Platelet aggregation was assessed after addition of serum from healthy dogs (n = 5) or dogs with ITP (n = 15) to platelet-rich plasma from a healthy donor dog. The aggregation responses to adenosine diphosphate, thrombin, and collagen/epinephrine were measured as the maximum aggregation observed after 2 minutes. In 13 of 15 dogs with ITP, maximal aggregation was significantly inhibited in response to ADP, thrombin, or collagen/epinephrine. The slope of the aggregation curve was decreased after addition of serum from 9 of 15 patients. A polyclonal rabbit anti-dog platelet antiserum induced inhibition of aggregation with all 3 agonists. Serum from control dogs neither inhibited nor activated platelet aggregation. Aggregation experiments were repeated with all 3 agonists after addition of patient immunoglobulin (Ig)G or IgG from a healthy dog to platelet-rich plasma. The IgG fraction from 9 of 10 dogs with ITP suppressed platelet aggregation. The IgG fraction from polyclonal rabbit anti-dog platelet antiserum inhibited platelet aggregation with all agonists. These results suggest that many canine ITP patients have circulating antibodies that, in addition to causing platelet destruction, may cause platelet dysfunction.     

Efficacy of high-dose methylprednisolone as a first-line therapy in adult patients with idiopathic thrombocytopenic purpura

Fifty-seven adult patients with idiopathic thrombocytopenic purpura (ITP) were treated with either conventional-dose prednisolone (CDP) (1 mg/kg/d, 36 patients) or high-dose methylprednisolone (HDP) (30 mg/kg/d, 21 patients), as first-line treatment. Patients in the HDP arm responded more rapidly (4.7 v 8.4 d), with a higher response rate (80% v 52.7%), and without severe side-effects. One quarter of the patients (3/12) who were non-responsive to CDP achieved complete remission when they were treated with HDP. The findings suggest that HDP may be a more effective first-line treatment than CDP for adult ITP, and it may also be preferred for life-threatening cases of ITP. However, these results must be confirmed by a randomized study prior to any change in the current practice of employing CDP as first-line treatment for adult ITP.     

Characteristics of the clinical findings in patients with idiopathic thrombocytopenic purpura who are positive for anti-phospholipid antibodies

It has been reported that anti-phospholipid antibodies are detected in some patients with idiopathic thrombocytopenic purpura (ITP). To study the significance of determination of anti-phospholipid antibodies in patients with ITP, clinical and laboratory findings were compared between patients whose sera were positive for these antibodies (Group A) and non-positive patients (Group B). Anti-cardiolipin antibody (aCL) was determined by enzyme-linked immunosorbent assay and lupus anticoagulant (LA) was determined by activated partial thromboplastin time (aPTT) and thromboplastin time inhibition test. Seven out of 27 cases of ITP belonged to Group A and 3 of the 7 were confirmed to have anti-phospholipid antibody syndrome (APS). There was a tendency for habitual abortion, and thrombosis, megakaryocytes in the bone marrow and platelet-associated IgG (PAIgG)-positive cells were more frequent in Group A than in Group B. However, it was difficult to discriminate APS from ITP alone, when there were no symptoms or signs of APS. Therefore, measurement of anti-phospholipid antibodies in ITP was thought to be useful for the differential diagnosis of APS and subsequently for the prevention of thrombosis.     

Immune thrombocytopenia in children: the immune character of destructive thrombocytopenia and the treatment of bleeding

It is now recognized that different forms of destructive thrombocytopenia due to antibody binding to platelets exist, which can be differentiated by sensitive new assays. Thus, the name has been changed from idiopathic to immune thrombocytopenic purpura (ITP). The immune character of ITP has been further supported by the success of treatment with human antibody concentrate-immunoglobulin treatment. During different studies of ITP in children, it has been recognized that only patients with bleeding in addition to a platelet count less than 20 x 10(9)/L need to be treated. The various forms of treatment are reviewed.     

Idiopathic thrombocytopenic purpura in a liver transplant recipient with previous primary biliary cirrhosis

The loss of immunotolerance has been implicated in the pathogenesis of both primary biliary cirrhosis (PBC) and idiopathic, immune-mediated thrombocytopenic purpura (ITP). An association between these two autoimmune diseases has been well described. We describe a 41-year-old woman in whom ITP developed 457 days after liver transplantation for PBC while receiving immunosuppressive medications sufficient to maintain allograft function. Our case report, the first to describe post-transplant ITP in association with PBC, demonstrates the persistence of the underlying immune dysregulation of PBC after transplantation. The practice of decreasing the dosage of immunosuppressive medication to maintenance levels after transplantation may unmask the effects of this defect in immunotolerance.