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July 2001
Immune thrombocytopenic purpura (ITP)
Discussion
Immune thrombocytopenic purpura is a common manifestation of HIV infection, occurring about 40 times more commonly in HIV-infected individuals than in the general population. At one time the prevalence of ITP in HIV-infected persons was thought to be as high as 40%, but with the advent of highly effective antiretroviral therapy, more recent estimates are much lower, ranging from 1-5%. Initial symptoms often include mucosal bleeding and a petechial rash, but life-threatening hemorrhage is not uncommon, especially in hemophiliacs. Some individuals remain remarkably asymptomatic despite platelet counts below 10,000/uL. Studies have demonstrated the presence of anti-platelet antibodies in HIV-related ITP, and increased levels of antibody and complement can be found on the surface of platelets even in those without signs of ITP. Clinical management of HIV-infected persons with ITP can be problematic. Therapy usually is not required until the platelet count drops below 30,000/uL, or the patient becomes symptomatic. Initial treatment usually includes corticosteroids or intravenous immunoglobulin. Some authors suggest that anti-D is a cheaper and more effective alternative to immunoglobulin. When medical options fail, splenectomy may be considered; however, this procedure can be associated with significant morbidity and is not always successful in increasing platelet counts. Other treatments, such as the use of danazol, have been tried, but efficacy has not been documented in large trials. Some series have noted an improvement in platelet counts when effective antiretroviral therapy is instituted.
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