Persistent Immune Thrombocytopenia Resistant to Immunosuppressive Therapy: What Is the Way Forward?

Immune thrombocytopenia purpura (ITP) involves autoimmune induced platelet destruction and decreased platelet production in part due to autoantibody destruction mechanisms. Most autoantibodies involved in its pathogenesis invoke autoreactive T cells and cytokine imbalance, and most drug therapies target these mechanisms. We describe a man in his late 40s, with a medical history of ITP, who presented with blood blisters on his mucosal surfaces and bruises on all four limbs with petechial rashes. He subsequently developed epistaxis and hemoptysis. In the recent past, he had been camping in Malta and felt feverish and nauseous on return. This was his first relapse of the disease in six years, and was unresponsive to prednisolone, IV immunoglobulins, and methylprednisolone, subsequently requiring romiplostim to recover platelet counts and reduce bleeding. When investigating the underlying causes of thrombocytopenia, aspects of virology and rickettsial serology were positive, requiring precautionary measures with long-term maintenance immunosuppression to prevent reactivation of infection.