Pathogenesis - Pathophysiology of

Immune Thrombocytopenic Purpura

ANGEL A AZ ALI A T RISNA PU TRI 121 5115

PRECEPT OR : DR. HARY GUS TIAN, SP.PD-
FINASIM-F HO
 Definition of ITP
Immune thrombocytopenic purpura (ITP) is
- an acquired bleeding disorder immune system destroys platelet
- characterised by increased platelet destruction and thrombocytopenia also
inhibition of platelet release by the megakaryocyte.
- a clinical syndrome: a decreased number of circulating platelets
(thrombocytopenia) manifests as
a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into
skin and mucous membranes (petechiae).
platelet count below the normal range generally defined as less than 150,000 cells/mm3.
The exact mechanism of the immune dysfunction, however, is generally not known. ITP
is initially caused by a B-cell abnormality, a T-cell disorder, an abnormality of
thrombopoiesis, or even from increased mononuclear phagocyte activation.
Forms OF ITP
Acute ITP
Acute ITP refers to the development of isolated thrombocytopenia with a
platelet count below the normal range (less than 150,000 cells/mm3) and
meeting the diagnostic criteria discussed. The use of the descriptor "acute"
refers not to the onset of the disorder, but rather its duration resolves most
often in less than 6 months
Chronic ITP
ITP is considered chronic ITP persisted greater than 3 months, if it has not
responded to a splenectomy and the platelet count has been less than 50,000
cells/mm3.
In the pediatric setting, chronic ITP is used only with duration of disease of 6
months or more.
 Classification OF ITP
Primary ITP : refers to thrombocytopenia in which apparent exogenous etiologic factors
are lacking and in which diseases known to be associated with secondary
thrombocytopenia have been excluded.
Secondary ITP: Autoimmune thrombocytopenia associated with drugs and with several
common diseases (i.e., collagen vascular disease, infections, lymphoproliferative
disorders, and Graves disease).
Drug induced ITP : quinidine, heparin, penicillin, procainamide, a-methyldopa,
sulfamethoxazole.
Autoimmune Thrombocytopenia : Systemic Lupus Erythematosus , APS
Limfoproliferative disorders: Chronic lymphocytic leukemia, hodgkin lymphoma.
Infections: HIV, Hepatitis C, H.pylory, infectious mononucleosis, cytomegalovirus, varicella or
ZOSTER, tuberculosis
Myelodysplastic syndrome
Agammaglobulinemia, hypogammaglobulinemia, immunoglobulin a deficiency
ITP
THROMBOPOIESIS
THROMBOPOIE
SIS
 Platelet
Peripheral Zone:
Glycocalyx
Glycoprotein (GP) adhesion & agregatin
trombocyte hemostasis.
GP Ia : adhesion collagen
GPIb, IIb//IIIa : von willebrand (vWF) receptor
adhesion to vascular subendotel
GP IIb/IIIa : fibrinogen receptor Trombocyte
aggregation.
Solgel Zone:
Microtubule, microfilamen, trombostenin, Cytoskeleton
Organella Zone:
Granule, mitochondria, granule , organela (lisosome
& reticulum endoplasm).
Granula heparin antagonis(platelet factor 4, PF4),
tromboglobulin, vWF, PDGF (platelet-derived growth
factor.
PATHOPHYSIOLOGY
AND
PATHOGENESIS
1951, Harrington and colleagues report infusion of plasma from patients with ITP
predictably induced thrombocytopenia in normal recipients. ITP could be caused by
antiplatelet antibody
Shulman and colleagues demonstrated that the responsible factor was an
immunoglobulin (Ig) of the IgG class that was species-specific and could be removed
from serum by absorption to and elution from normal human platelets.
thrombocytopenic effect of ITP plasma was dose dependent and associated with
globulin fraction. And suggested that splenic clearance was the major mechanism of
trombocytopenia.
1970 chronic ITP patiens : elevated level of platelet-associated immunoglobulin G
(PAIgG).
1982, van Leeuwen identified platelet membrane glycoprotein IIb/IIIa as a dominant
antigen by demonstrating that the autoantibodies eluted from ITP platelets bound to
normal platelets (but not to platelets from patients with Glanzmann thrombasthenia.)
The assay showed , majority of antiplatelet antibodies on ITP patients are directed
against GPIIb/IIIa(80%) , and the remainder against GPIb/IX complex and the other
(GPIV , GPIa/Iia). Most antiplatelet autoantibodies are IgG, remainder are IgM, and IgA.
Antibody-coated platelet bind antigen-presenting cells through Fcy Receptors, Primarily
in the spleen , also in mononuclear phagocyte system.
Immunologic mechanisms:
The most common mechanism involved in ITP is development of antiplatelet
antibodies through the activation of B-lymphocytes.
- glycoprotein IIb/IIIa (the fibrinogen receptor).
- Some antibodies can affect the earlier lineage megakaryocytes and impair
their production of platelets in the bone marrow.
- It is now becoming recognized that cytotoxic T-lymphocytes are also
involved in the pathophysiology of ITP.
ITP pathogenesis involves a complex network of systemic events
interaction between B- and T-lymphocytes and inflammatory cytokines.
a central deficiency of immune
tolerance due to defects in both
Tregs and Bregs. increased IFN-y,
IL-2 and IL-17 as well as
decreased immunosuppressive IL-
10, TGF- and IL-4 promoting
autoantibody development
enhanced by a pro-inflammatory
cytokine profile autoreactive
antibodies associated with
impaired T and B cells
destruction of platelets and defects
in thrombopoiesis and
megakaryopoiesis.
Autoantibody
In immune thrombocytopenic purpura (ITP) abnormal autoantibody, usually
immunoglobulin G (IgG) with specificity for one or more platelet membrane glycoproteins
bind to circulating platelet membranes.
Autoantibody-coated platelets induce Fc receptor-mediated phagocytosis by mononuclear
macrophages
Autoantibody stimulation
In chronic ITP, for unknown reasons, membrane glycoproteins (GPs) on the surface of
platelets become immunogenic, stimulating the production of platelet autoantibodies.
In acute ITP, the stimulus for autoantibody production is also unknown; platelet membrane
cryptantigens may become exposed by the stress of infection, or pseudoantigens may be
formed by the passive adsorption of pathogens on platelet surfaces
Autoantibody specificity
In persons with chronic ITP, approximately 75% of autoantibodies are directed against
platelet GPIIb/IIIa or GPIb/IX GP complexes. Presumably, the remaining 25% are directed
against other membrane epitopes, including GPV, GPIa/IIa, or GPIV
Platelet destruction
The mononuclear macrophage system of the spleen is responsible for
removing platelets in ITP,
Platelets are sequestered and destroyed by mononuclear macrophages,
which are neither reticular nor endothelial in origin. Therefore, the former
designation of reticuloendothelial system is considered imprecise.
Immune destruction of immunoglobulin-coated platelets is mediated by
macrophage IgG Fc (Fc gamma RI, Fc gamma RII, and Fc gamma RIII) and
complement receptors (CR1, CR3).
The spleen key organ of ITP
Role of the spleen
platelet autoantibodies are formed in the white pulp
The spleen is the site of autoantibody production (white pulp);
mononuclear macrophages in the red pulp destroy immunoglobulin-coated platelets.
site of phagocytosis of autoantibody-coated platelets (red pulp).
The slow passage of platelets through splenic sinusoids with a high local concentration of antibodies and
Fc-gamma receptors on splenic macrophages lend to the uniqueness of the spleen as a site of platelet
destruction.
Low-affinity macrophage receptors, Fc gamma RIIA, and Fc gamma RIIIA bind immune-complexed IgG
and are the key mediators of platelet clearance.
If bone marrow megakaryocytes cannot increase production and maintain a normal number of
circulating platelets, thrombocytopenia and purpura develop.
Impaired thrombopoiesis is attributed to failure of a compensatory increase in thrombopoietin
and megakaryocyte apoptosis.
 platelet-specific
autoantibodies Bind to
autologous platelets
rapidly cleared from the
circulation by the
mononuclear phagocyte
system via macrophage Fc
receptors

- Platelet survival shortened

(abnormal splenic activity)

Antibody coated platelets

destroyed by tissue
macrophages (spleen,liver,
Bone marrow)
 T-cell clones (having
different antigen Clonal B-cell proliferation
Presentation of
specificities )
platelets antigens :
induce B-cell clones
By activated APC.
to produce antibodies
Activated CD4+ T-
against distinct
cell clones, and
platelets antigen. CD 8 + cytotoxic T-Cells
antigen-specific T-
through cell-mediated
cell clones.
Autoreactive CD4+ T- destruction of the platelets,
helper cells in patients supression of megakaryocyte
Autoantibodies with ITP recognize a apoptosis impaired platelet
under control of T- modified GPIIb/IIIa production.
helper cell and molecule ( Cryptic
cytokines. Epitope Theory)
GPIIb/IIIa- reactive CD4+ T cell Complement activation
promote production of anti- increase platelet- associated
Abnormal T-cell C3,C4, C9 bind platelets
GPIIb/IIIa antibodies capable of
responses lysis platelet
binding normal platelet, and the
differentiation of
clones respond chemically
autoreactive B-cell clones And secondary in importance to
modified GPIIb/IIIa and
and autoantibody platelet IgG and/or the result of
recombinant GPIIb/IIIa-
secretion antiplatelet IgM
fragments

Studies of Dameshek and
Miller decreased platelet
production in acute and
chronic ITP, despite the interfere with the maturation
presence of increased
numbers of megakaryocytes
in marrow.
Autoantibodies that target
the GPIb/IX/V complex
Autoantibodies againsts
decreasing platelet
platelet Glycoproteins
production.
of megakaryocytes
(GPIb antibodies inhibit
reduced platelet production
megakaryopoiesis &
proplatelet formation)

platelets confirmed rapid platelet turnover platelet survival time as short

as several minutes.
This finding is presumed to be due to a direct effect of antibody on
megakaryocyte maturation or platelet release.
An antibody effect on megakaryocytes is consistent with the fact that
megakaryocytes are known to express GPIIbIIIa and GPIbIX on their
surfaces that most ITP antiplatelet autoantibodies react with one or both of
these GP complexes.

ITP marrow has normal/ increased
ITP number of megakaryocytes.
- Compensation: increased platelet
production associated w/ large
platelets.
(large young platelets have increased
granular contents and enhanced
function)
The large size and increasend functions of
platelets in ITP atribute to the actions
of TPO (major regulator of
megakaryopoiesis and thrombopoiesis)
TPO synthetized in liver, kidney, muscle,
marrow. enhace megakaryocytes colony
formation, increase the size , number,
and ploidy megakaryocyte and platelet
production .
Platelet having TPO receptors, remove
the hormones from the circulation,
accounting for the inverse relationship
between TPO and platelet level.

TPO level elevated in patients with

thrombocytopenia associated with
megakaryocytic hypoplasia ( aplastic
anemia / acute leukemia)

ITP patients normal / slightly elevated

TPO levels in plasma / serum (lower than
concentration found on thrombocytopenia
from megakaryocytic hypoplasia)
ITP
severity and frequency of hemorrhagic manifestations correlate with the
platelet count
Bleeding after trauma without spontaneous hemorrhage is usual Pts
platelet counts >50,000/l.
Thrombocytopenia associated with counts between 10,000 and 50,000/l
spontaneous hemorrhagic (such as ecchymoses and petechiae.)
platelet counts <10,000/l risk for serious morbidity and mortality from
bleeding.
increased risk of bleeding include : a history of bleeding, those with
additional bleeding diatheses, and patients >60 years of age.
SECONDARY AUTOIMMUNE
THROMBOCYTOPENIC PURPURA
Drug induced
ITP
idiosyncratic reaction:
- trimethoprim- sulfamethoxazole
complement- or
- gold salts
noncomplement-
- immune-mediated heparin-
activating antibodies
induced thrombocytopenia react with platelets
DRUG-INDUCED PLATELET
ANTIBODIES
It is not clear whether there are predisposing
risk factors for most of the drugs that cause
ITP:

- evidence suggests risk of developing

antibodies to gold salts depends on host HLA
type (HLA-DR3 antigen.)
 antibodies bind to platelet
membrane glycoproteins in the
IIb/IIIa or the Ib/V/IX complex
(through the Fab portion of the
antibody molecule )

antibodies to
heparinbin
d to a
heparin- the immune complex binds
platelet to the platelet membrane (via
factor 4 the Fc portion of the antibody
complex molecule )
 Autoimmune Thrombocytopenia
in Systemic Lupus Erythematosus
ITP in SLE appears to result from
immunologic platelet injury and (identical It is unclear, however, whether they
to primary ITP in most respects) a are specific to these glycoproteins or
positive antinuclear antibody test cross-reactive.

ITP in SLE because of specific platelet

autoantibodies or immune complex
deposition on platelets platelet AntiPhospholipidSyndrome
autoantibodies to platelet membrane Antibodies in ITP sera to bind to
glycoproteins bind to platelet membrane glycosphingolipids, and cardiolipin.
gpIIb/IIIa or Ib/IX/V.
two studies identified:
antiphospholipid antibodies (lupus
anticoagulant activity or anticardiolipin
antibodies)
Immune Thrombocytopenia in
Other Disorders
ITP has been reported in association with infections, lymphoproliperative ,
neoplasms, and thyroid disease.
it is unknown
increased platelet destruction involves antibody binding
immune complex deposition, and/or antibody-mediated complement activation.
ITP is a well-known complication of chronic lymphocytic leukemia
It has also been reported in patients with other lymphoproliferative disorders
( Hodgkin disease), solid tumors has also been thought to most likely be
immune-mediated.
Thrombocytopenia may accompany Graves disease and Hashimoto
thyroiditis it is not certain that it is immunologically mediated.
Platelet-associated IgG has been increased there may also be an element of
enhanced reticuloendothelial phagocytosis.
 Cross-reaction of antigens, (on
bacteria or viruses) stimulate
self- reacting B cells via
molecular mimicry.
(Helicobacter pylori and varicella
zoster virus.) A number of
antigens are able to provide T-
independent signals to B cells.
Polyclonal activation of B
cells by stimuli as diverse
as Epstein Barr virus
(EBV), malaria and graft-
versus-host disease
(GVHD) may result in
autoantibodies being
formed.
Interruption of the checkpoints
the immature B cells producing
autoreactive antibodies are
removed from the circulation
increase in the numbers of
autoantibodies.
autoimmunity : platelets can
present themselves to the
immune system by membrane
major histocompatibility
complex (MHC) class I
breakdown of the suppressor molecules enabling
cell and also of the anti- destruction by cell-mediated
idiotype regulatory networks mechanisms activated
autoimmune reactions. platelets increase their
expression of CD40L
(linking autoimmunity and immunological recognition
immunodeficiency and autoimmunity to platelets.
therefore may be the one
most pertinent to ITP.)
Nonetheless, immune
recognition as a result of HLA
may also be critical in
development of autoimmunity in
heterogeneous populations.
Virus-associated ITP
viral infection is cleared normally but initiates ITP probably molecular mimicry or B-cell
stimulation
ITP is often associated with HIV, hepatitis C virus (HCV) infection and EBV infection.
HIV causes T-cell immunodeficiency decrease in T- helper CD4 cells The autoimmune diseases
that predominate in AIDS are generally CD8-driven
HIV also B-cell stimulation via loss of T-cell regulation, and a wide variety of autoantibodies on
HIV.
The relationship between HCV and ITP is less clear virus appears to generally increase the
production of a number of autoantibodies
EBV direct effect on B cells lymphoproliferation and increased antibody formation. (typically
transient in immunocompetent patients)
viral infections have other effects in the immune system macrophage activation is an important
component in disease severity. The increased antibody-coated platelet destruction seen with
macrophage activation could explain viral-induced exacerbation of ITP and cyclical
thrombocytopaenia.
 ITP on HIV
Thrombocytopenia occurs in the setting of HIV infection due to decreased
production, increased destruction, or splenic sequestration secondary to other
causes such as lymphoma or hepatitis C.
also, platelet consumption associated with thrombotic thrombocytopenia purpura
(TTP).
One study demonstrated that platelet-associated immune complexes are made
up of antiplatelet integrin, glycoprotein IIIa (3), antibody (Ab), and its anti-
idiotype blocking Ab. Some of the antibodies also bound epitopes with homology
to HIV-1 proteins nef, gag, env, and pol, suggesting molecular mimicry
trombocytopenia
Increased platelet destruction.
(accelerated platelet destruction)
HIV non specific deposition of complement and immune complexes on
platelets platelets destruction. (level of platelet-bound Ig and complement
components 4x> ITP)
HIV triggering a large repertoire of immune complexes platelets
destruction.
immune complexes ( IgG anti-F(ab)2 antibodies) found in homosexual
individual with HIV-ITP.) react against F(ab)2 antibodies from HIV-ITP.
immune complexes bound to platelets = corespond to IgG anti-F(ab)2
antibodies.
Antibodies against CD4 & CD4 receptors Gp120 immune complexes bind
platelets thrombocytopenia.
(Anti-idiotype )High affinity antibodies ( usually IgM type) against platelet GPIIIa
(react on the molecule located between AA 49 and 66) destruction platelet induced
by anti-GPIIIa induce platelet fragmentation through reactive oxygen (H2O2), NADPH
oxidase pathway(membrane-damaging peroxide and other reactive oxygen species.)
Epitope : cross reactivity antibodies directed against viral antigens gp120 and p24 with
platelet glycoproteins (molecular mimicry between HIV-gp 160/120 and platelet gp
IIb/IIIa)
antibody-induced destruction of platelets arises from the absorption of immune
complexes against HIV onto the platelet F c receptor, thus providing a "free" Fc portion
for subsequent macrophage binding and phagocytosis.
Circulating immune complexes : talin-H is a cleavage product of talin generated by
calpain when platelet activated or by HIV-1 protease. antitalin antibodies found on a
serum HIV-ITP unknown role? ( directed against a cytoskeletal antigen??
Decreased platelet production.
HIV-ITP increase level of TPO supporting the notion ineffective platelet production
Deffect on level of megakaryopoiesis decrease level of megakaryocyte progenitors in marrow.
HIV-1 entry cells by interaction viral envelope glycoprotein gp120 with CD4 and correceptor on the
host cells plasma membrane ( C-C chemokine receptor-5 (CCR5) or CXC chemokine receptor-4 (CXCR-
4). all these receptor expressed by megakaryocyte
CXCR4, as the coreceptor for HIV on megakaryocytic progenitors, megakaryocytes, and platelets.
HIV CD4+ affect megakaryocyte infection of the megakaryocite and precursors & cells of the
marrow. deffective modulation hematopoiesis
T cell of infected patients reduce growth of CFU for granulocytes, erythrocytes,
monocytes/macrophages, megakaryocytes. depleted of T cells in marrow.

TTP on HIV : diminished activity of VWF-cleaving protease a disintegrin and metalloproteinase with
trombospondin repeats (ADAMTS)13 is inconsistent .
ITP on HCV
The diagnosis of immune thrombocytopenia is confounded in patients with
advanced liver disease because of hypersplenism and decreased production
of TPO.
Possible mechanisms
immune destruction include binding of HCV followed by anti-HCV antibody
to the platelet membrane
circulating anti-viral immune complexes
and direct infection of megakaryocytes with expression of HCV RNA in
platelets.
Bone marrow production may be suppressed by HCV126 or interferon
antiviral treatment.
Bacteria-associated ITP: H. pylori
The associations between pathogens, such as H. pylori, and ITP molecular
mimicry (production of antibodies to the pathogen causes the production of
antibodies to self).
Platelet eluates from patients who were both H. pylori-negative and H. pylori-
positive recognise H. pylori cytotoxin-associated gene A (CagA) protein
chronic infection change cytokine milieu encourage loss of tolerance
and stimulate B cells.
Helicobacter pylori has been described to both causes a Th1-type of
response to directly stimulate B cells.
AIHA and ITP related CLL
Mechanisms of autoimmune disease in CLL.
(A) CLL cells red blood cell antigens and act as antigen presenting cells inducing a T-
cell response and the formation of polyclonal antibodies by normal B cells indirectly
provoking autoimmune hemolytic anemia.
(B) CLL cells express inhibitory cytokines that alter tolerance, escape of self-reactive
cells.
(C) Rarely CLL cells effector cells that secrete a pathological monoclonal autoantibody.
IgMs have anti-red cell reactivity.
(D) In turn, CLL cells may be stimulated through their polyreactive BCR that recognizes
auto-antigens.
Several clinical and biological features of CLL increased risk of developing
autoimmune cytopenia.
Nevertheless, both AIHA and ITP have been associated unmutated IGHV
gene, high ZAP70 expression, and increased serum beta-2 microglobulin levels.
The stereotyped BCR seen in CLL reactive with autoantigens.
The possibility that therapy could trigger autoimmune cytopenia treatment
with purine analogs (particularly fludarabine) could be associated with a higher
frequency of autoimmune cytopenia.
This was thought to be related to prolonged suppression of CD4+ T cells by
fludarabine.
A decrease in CD4+CD25+FOXP3+ regulatory T cells (Tregs) has been shown to
lead to AID (Tregs are highly sensitive to fludarabine)
THANK YOU ..
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