Role of Helicobacter pylori Eradication Therapy on Platelet Recovery in Chronic Immune Thrombocytopenic Purpura.
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune phenomenon, hence also called immune thrombocytopenic purpura (ITP). In this disease antibody coated platelets are phagocytosed by immune cells . ITP may be categorized as recently diagnosed ITP, persistent ITP (3-12-month duration) and chronic ITP ([greater than or equal to] 12 months) [2, 3]. Association between H. pylori and ITP has already been established. H. pylori is also associated with similar autoimmune disorders like pernicious anemia, rheumatoid arthritis, and sicca syndrome .
Morphologically, H. pylori is a Gram-negative spirochete which colonizes the stomach mucosa. H. pylori infection is implicated in the pathogenesis of gastric and duodenal ulcers. Persistent or recurrent H. pylori infection is a known risk factor for gastric lymphoma and adenocarcinoma . H. pylori eradication therapy (HPET) has shown promising results in the management of peptic ulcers, chronic gastritis, and even regression of lymphoma of stomach . Pathogenetic mechanisms involved in H. pylori infection include mucosa adhesion, flagella, and urease production. Cytotoxic associated gene A (CagA) and vacuolating cytotoxin A (VacA) are proven virulent factors which interact with gastric mucosa for colonization and cause infection by H. pylori . Cell wall lipopolysaccharide and neutrophil attracting protein (HP-NAP) also participate in the virulence chain [8, 9]. Chronic immune thrombocytopenic purpura (chronic ITP) is linked as one of the extraintestinal manifestations of H. pylori disease . Chronic ITP is reported to improve by effective H. pylori eradication therapy (HPET) [11, 12]. The role of HPET however remains controversial as some studies have reported an improvement in platelet count but others have failed to demonstrate any benefit [4, 13, 14]. This study was specifically designed to evaluate effect of H. pylori eradication therapy (HPET) on platelet count recovery in chronic ITP patients presenting at the Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro, Sindh.
2. Materials and Methods
This interventional and prospective study was conducted in compliance with Helsinki's declaration 2000 and with an approval by institutional ethical committee at LUMHS, Jamshoro, from 2014 to 2015. A total of 85 subjects were recruited through convenient sampling. Written informed consent was taken. The inclusion criteria comprised diagnosed cases of chronic ITP. Patients with major comorbidities, concomitant malignancies, other autoimmune phenomenon, or aplastic anemia were excluded. A comprehensive questionnaire, including detailed history and physical examination, was filled out for each patient by a clinician.
Venous blood from each patient was collected into two EDTA containing sample collection tubes, each one 3 ml in volume. Completeblood count(CBC), including hemoglobin (Hb) estimation and platelet count, using automated cell analyzer (Sysmex XN 1000i Tokyo, Japan) and peripheral blood smear examination, stained with Leishman's stain, were performed on all the samples.
After the collection of stool samples in clean containers, Rapid Strip HpSA (Rapid Immunochromatography) was performed for the detection of Helicobacter pylori antigens in stool.
For bone marrow examination, aspiration was carried out under local anesthesia (2% xylocaine); smear was prepared and stained to look for the number and morphology of megakaryocytes.
2.1. Standard H. pylori Eradication Therapy. Amoxicillin 1 gram 2x daily, Clarithromycin 500 mg 2x daily, and a proton pump inhibitor 40 mg 2x daily were given for a duration of 2 weeks. The eradication was confirmed with HpSA stool test on the 7th posttreatment day .
2.2. Follow-Up Assessment. All the study patients were followed for a period of 6 months. These were tested for CBC on weekly basis in the first month. Thereafter, weekly monitoring was continued in those on risk of bleeding (platelet count < 10, 000/[micro]L), while the others were checked on a two-week basis. The disease response was categorized into the following three groups:
(a) Complete response (CR): platelet count [greater than or equal to] 150 x [10.sup.9] [l.sup.-1]
(b) Partial response (PR): platelet count 50-150 x [10.sup.9][l.sup.-1]
(c) No response (NR): platelet count <50 x [10.sup.9][1.sup.-1] or an increase of <20 x [10.sup.9][1.sup.-1] after at least 6 months of follow-up .
2.3. Statistical Analysis. Data analysis was performed on SPSS version 22.0. Kolmogorov-Smirnov test was used for normality of data for parametric variable analysis. Continuous variables were analyzed by student's f-test and categorical variables by Chi-square test. P level of significance was taken at [less than or equal to] 0.05.
A total of 85 patients were enrolled into the study; 32 (37.6%) were males and 53 (62.3%) were females. H. pylori positive cases were found to have a mean age of 43.89 [+ or -] 7.06 years, while the negative ones had a mean age of 44.75 [+ or -] 7.91 years. The parameters including Hb and hematocrit are documented in Table 1. H. pylori stool antigen (HpSA) was detected in 34 (40%) of subjects, and 51 (60%) were HpSA negative (Figure 1). Platelet counts before H. pylori eradication were noted as 48.56 [+ or -] 21.7 million/[micro]L which increased to 94.2 [+ or -] 26.8 million/[micro]L after eradication therapy (Table 2). All the study patients were followed up for a period of 6 months. A significant sustained response was found in H. pylori eradicated cITP cases. On the other hand, H. pylori negative cases showed only a mild transient response. Complete recovery (CR), partial recovery (PR), and no response (NR) of platelet recovery in HpSA positive cases (n = 34) were observed in 19 (55.8%), 10 (29.4%), and 5 (14.7%) cases, respectively (Table 3).
Bone marrow examination mostly showed increased number of megakaryocytes with abnormal morphology and distribution. Majority of the megakaryocytes were smaller in size. Other cell lineages showed normal morphology.
An informal connection between H. pylori infection and immune thrombocytopenic purpura (ITP) is suggested by various clinical studies demonstrating platelet count response in approximately 50% of patients following H. pylori eradication . Effects of H. pylori eradication therapy (HPET) on platelet recovery in chronic immune thrombocytopenic purpura were first reported by Gasbarrini et al. in 1998 . An analysis of 25 reported series worldwide showed that eradication was successful in 671 of 792 (84.7%) patients . Inaba et al. had reported similar findings as H. pylori eradication therapy improved platelet counts . The authors of present study hold the view that H. pylori is linked with abnormal immune reaction producing platelet destruction. On the contrary, Stasi et al. and Gan et al. reported no improvement in circulating platelets after HPET [10, 21]. Geographical variations, sampling techniques and sample size, faulty study designs, H. pylori strains, drug compliance, drug efficacy, systemic bias, and research bias may be the main confounding factors.
The prevalence of H. pylori infection in chronic ITP patients varies markedly. We found H. pylori infection in 40% of the study cITP patients. A previous study, conducted in Italy, showed a H. pylori prevalence rate of 50% in cITP patients. In another study from Japan 75% of the cITP patients were found to have H. pylori infection. However, studies conducted in French and North American Caucasian cITP patients showed a low prevalence rate . A prevalence rate of 50-80% has been marked in studies from Japan, Iran, and Korea [22-24]. It has already been shown that after HPET treatment the cITP of shorter duration responds better in comparison to the long standing ones [1, 21]. In the current study, complete response (CR), partial response (PR), and no response (NR) of platelet recovery in HpSA positive cases (n = 34) were noted in 19 (55.8%), 10 (29.4%), and 5 (14.7%) cases, respectively. The response found was statistically significant (P = 0.0001). Our findings of platelet recovery are consistent with those of previous studies [1, 15, 21]. All the study patients were followed up for a period of 6 months. A significant sustained response was found in H. pylori eradicated cITP cases. On the other hand, H. pylori negative cases showed only a mild transient response. Patients with PR and NR are speculated to have other aetiologies including HIV or HCV infection or have previously been treated with interferons or other antiviral therapy interfering with megakaryopoiesis.
Brito et al.  and Payandeh et al.  reported a recovery in platelet counts after HPET treatment at 6-12-month follow-up which is consistent with the current study.
We conclude that 40% of the local cITP patients are H. pylori infected and that H. pylori eradication therapy in these individuals significantly improves the platelet counts. Further studies on a larger cohort of patients, with a longer follow-up, will allow a better insight into the true prevalence of H. pylori infection and the duration of remission. Such studies will also conceivably endorse clarity of actual prevalence and understanding of mechanisms underlying the response to eradication therapy.
The authors declare that they have no competing interests.
Khan Sheema designed, collected, and analyzed the data and wrote the manuscript. Ujjan Ikramdin supervised the study, helped in data analysis, and secured funding. Naz Arshi helped in manuscript writing and reviewed the data analysis. Naz Farah provided the patients samples and helped in study design. Sheikh Imran contributed to study design, specimen collection, and clinical data analysis.
The authors would like to thank all patients who participated in this study, clinicians, and staff of diagnostic and research laboratory. They also like to thank University of LUMHS for funding this project.
 R. N. Noonavath, C. P. Lakshmi, T. K. Dutta, and V. Kate, "Helicobacter pylori eradication in patients with chronic immune thrombocytopenic purpura," World Journal of Gastroenterology, vol. 20, no. 22, pp. 6918-6923, 2014.
 T. Kuhne, W. Berchtold, L. A. Michaels et al., "Newly diagnosed immune thrombocytopenia in children and adults: a comparative prospective observational registry of the Intercontinental Cooperative Immune Thrombocytopenia Study Group," Haematologica, vol. 96, no. 12, pp. 1831-1837, 2011.
 D. Provan, R. Stasi, A. C. Newland et al., "International consensus report on the investigation and management of primary immune thrombocytopenia," Blood, vol. 115, no. 2, pp. 168-186, 2010.
 N. Rostami, M. Keshtkar-Jahromi, M. Rahnavardi, M. Keshtkar-Jahromi, and F. S. Esfahani, "Effect of eradication of Helicobacterpylori on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura: a controlled trial," American Journal of Hematology, vol. 83, no. 5, pp. 376-381, 2008.
 S. Suerbaum and P. Michetti, "Helicobacter pylori infection," New England Journal of Medicine, vol. 347, no. 15, pp. 1175-1186, 2002.
 R. Sato, K. Murakami, K. Watanabe et al., "Effect of Helicobacter pylori eradication on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura," Archives of Internal Medicine, vol. 164, no. 17, pp. 1904-1907, 2004.
 A. A. Memon, N. R. Hussein, V. Y. Miendje Deyi, A. Burette, and J. C. Atherton, "Vacuolating cytotoxin genotypes are strong markers of gastric cancer and duodenal ulcer-associated Helicobacter pylori strains: a matched case-control study," Journal of Clinical Microbiology, vol. 52, no. 8, pp. 2984-2989, 2014.
 L. P. Andersen, "Colonization and infection by Helicobacter pylori in humans," Helicobacter, vol. 12, no. 2, pp. 12-15, 2007
 A. Amedei, A. Cappon, G. Codolo et al., "The neutrophil-activating protein of Helicobacter pylori promotes Th1 immune responses," The Journal of Clinical Investigation, vol. 116, no. 4, pp. 1092-1101, 2006.
 G. G. Gan, A. L. Norfaizal, P. C. Bee, E. F. M. Chin, A. H. Habibah, and K. L. Goh, "Helicobacter pylori infection in chronic immune thrombocytopenic purpura patients in Malaysia," Medical Journal of Malaysia, vol. 68, no. 3, pp. 231-233, 2013.
 H. Suzuki, F. Franceschi, T. Nishizawa, and A. Gasbarrini, "Extragastric manifestations of Helicobacter pylori infection," Helicobacter, vol. 16, no. 1, pp. 65-69, 2011.
 K. H. Shaikh, S. Ahmed, M. Ayyub, and J. Anwar, "Association of Helicobacter pylori infection with idiopathic thrombocytopenic purpura," Journal of the Pakistan Medical Association, vol. 59, no. 10, pp. 660-663, 2009.
 G. Emilia, G. Longo, M. Luppi et al., "Helicobacter pylori eradication can induce platelet recovery in idiopathic thrombocytopenic purpura," Blood, vol. 97, no. 3, pp. 812-814, 2001.
 E. R. Ahn, M. P. Tiede, W. Jy, C. J. Bidot, V. Fontana, and Y. S. Ahn, "Platelet activation in Helicobacter pylori-associated idiopathic thrombocytopenic purpura: eradication reduces platelet activation but seldom improves platelet counts," Acta Haematologica, vol. 116, no. 1, pp. 19-24, 2006.
 K. Fujimura, M. Kuwana, Y. Kurata et al., "Is eradication therapy useful as the first line of treatment in Helicobacter pylori-positive idiopathic thrombocytopenic purpura? Analysis of 207 eradicated chronic ITP cases in Japan," International Journal of Hematology, vol. 81, no. 2, pp. 162-168, 2005.
 D. Vaira, N. Vakil, M. Menegatti et al., "The stool antigen test for detection of Helicobacter pylori after eradication therapy," Annals of Internal Medicine, vol. 136, no. 4, pp. 280-287, 2002.
 D. M. Arnold, A. Bernotas, I. Nazi et al., "Platelet count response to H. pylori treatment in patients with immune thrombocytopenic purpura with and without H. pylori infection: a systematic review," Haematologica, vol. 94, no. 6, pp. 850-856, 2009.
 A. Gasbarrini, F. Franceschi, R. Tartaglione, R. Landolfi, P. Pola, and G. Gasbarrini, "Regression of autoimmune thrombocytopenia after eradication of Helicobacter pylori," The Lancet, vol. 352, no. 9131, p. 878, 1998.
 R. Stasi and D. Provan, "Helicobacter pylori and chronic ITP," Hematology, vol. 2008, no. 1, pp. 206-211, 2008.
 T. Inaba, M. Mizuno, S. Take et al., "Eradication of Helicobacter pylori increases platelet count in patients with idiopathic thrombocytopenic purpura in Japan," European Journal of Clinical Investigation, vol. 35, no. 3, pp. 214-219, 2005.
 R. Stasi, A. Sarpatwari, J. B. Segal et al., "Effects of eradication ofHelicobacterpylori infection in patients with immune thrombocytopenic purpura: a systematic review," Blood, vol. 113, no. 6, pp. 1231-1240, 2009.
 M. Michel, N. Cooper, C. Jean, C. Frissora, and J. B. Bussel, "Does Helicobater pylori initiate or perpetuate immune thrombocytopenic purpura?" Blood, vol. 103, no. 3, pp. 890-896, 2004.
 J. Y. Yim, N. Kim, S. H. Choi et al., "Seroprevalence of Helicobacter pylori in South Korea," Helicobacter, vol. 12, no. 4, pp. 333-340, 2007.
 M. Michel, M. Khellaf, L. Desforges et al., "Autoimmune thrombocytopenic purpura and Helicobacter pylori infection," Archives of Internal Medicine, vol. 162, no. 9, pp. 1033-1036, 2002.
 H. S. H. Brito, J. A. P. Braga, S. R. Loggetto, R. S. MacHado, C. F. H. Granato, and E. Kawakami, "Helicobacter pylori infection & immune thrombocytopenic purpura in children and adolescents: a randomized controlled trial," Platelets, vol. 26, no. 4, pp. 336-341, 2015.
 M. Payandeh, A. Fekri, M. Sadeghi, and E. Sadeghi, "Clinical variables among adult patients with chronic idiopathic thrombocytopenic purpura in West Iran," Iranian Journal of Blood and Cancer, vol. 7, no. 2, pp. 79-83, 2015.
Khan Sheema, (1) Ujjan Ikramdin, (1) Naz Arshi, (2) Naz Farah, (1) and Sheikh Imran (1)
(1) Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
(2) National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan
Correspondence should be addressed to Ujjan Ikramdin; firstname.lastname@example.org
Received 1 August 2016; Accepted 8 November 2016; Published 17 January 2017
Academic Editor: Francesco Franceschi
TABLE 1: Baseline demographic and clinical characteristics of study patients (N = 85). Parameter HpSA positive HpSA negative Age (years) 43.89 [+ or -] 7.06 44.75 [+ or -] 7.91 Male 12 20 Female 22 31 Hemoglobin (g/dl) 11.54 [+ or -] 1.68 12.19 [+ or -] 2.06 Hematocrit (%) 45.0 [+ or -] 7.5 47.0 [+ or -] 8.0 RBC (million/[micro]l) 2.91 [+ or -] 0.49 3.34 [+ or -] 0.55 WBC (per [micro]l) 6283.7 [+ or -] 0.310 6239.0 [+ or -] 0.311 Platelets (x [10.sup.3] 12.3 [+ or -] 3.7 13.5 [+ or -] 4.1 /[micro]l) Parameter P value * Age (years) 0.53 Male -- Female -- Hemoglobin (g/dl) 0.12 Hematocrit (%) 0.30 RBC (million/[micro]l) 0.0001 WBC (per [micro]l) 0.01 Platelets (x [10.sup.3] 0.9 /[micro]l) HpSA: Helicobacter pylori stool antigen; N: total number of patients. * Based on Student's t-test. TABLE 2: Platelet counts before and after H. pylori eradication therapy (N = 34). Platelet counts Mean SD P value Before H. pylori eradication 48.56 21.75 0.0001 After H. pylori eradication 94.29 26.85 N: number of patients. TABLE 3: Evaluation of platelet counts in response to HPET in HpSA positive patients (N = 34). Platelet response Number Percentile (%) P value Complete response (Cr)* 19 55.8 Partial response (Pr)** 10 29.4 0.0001 No response (Nr)*** 5 14.7 HPET: H. pylori eradication therapy; HpSA: H. pylori stool antigen. * Platelet count 150 x [10.sup.-9] [L.sup.-1]. ** Platelet count 50-150 x [10.sup.-9] [L.sup.-1A. *** Platelet count < 50 x [10.sup.-9] [L.sup.-1] or an increase of <20 x [10.sup.-9] [L.sup.-1] after at least 6 months of follow-up . FIGURE 1: H. pylori infection in chronic immune thrombocytopenic purpura (n = 85). HpSA positive n = 34 (40%) HpSA negative n = 51 (60%) Note: Table made from pie chart.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research Article|
|Author:||Sheema, Khan; Ikramdin, Ujjan; Arshi, Naz; Farah, Naz; Imran, Sheikh|
|Publication:||Gastroenterology Research and Practice|
|Date:||Jan 1, 2017|
|Previous Article:||Video-Assisted Anal Fistula Treatment: Pros and Cons of This Minimally Invasive Method for Treatment of Perianal Fistulas.|
|Next Article:||Acute Colonic Pseudo-Obstruction with Feeding Intolerance in Critically Ill Patients: A Study according to Gut Wall Analysis.|