Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstract
Abstracts
Brief Report
Case Report
Case Report and Review
Case Series
Commentary
Editorial
Erratum
How do I do it
How I do it?
Invited Editorial
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Mini Review
Original Article
Original Articles
Others
Review Article
Short communication
Short Paper
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstract
Abstracts
Brief Report
Case Report
Case Report and Review
Case Series
Commentary
Editorial
Erratum
How do I do it
How I do it?
Invited Editorial
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Mini Review
Original Article
Original Articles
Others
Review Article
Short communication
Short Paper
View/Download PDF

Translate this page into:

Letter to Editor
ARTICLE IN PRESS
doi:
10.25259/JLP_259_2024

Immune thrombocytopenia with retinopathy of prematurity

Department of Neonatology All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.
Department of Opthalmology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.

*Corresponding author: Chetan Khare, Department of Neonatology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India. drchetankhare@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Khare C, Karkhur S. Immune thrombocytopenia with retinopathy of prematurity. J Lab Physicians. doi: 10.25259/JLP_259_2024

Dear Editor,

A growth-faltered preterm newborn weighing 1150 g was referred to our retinal unit for advanced retinopathy of prematurity. The infant had three interrelated ailments at presentation: Severe thrombocytopenia (<10,000/mm3), rashes, and advanced fibroproliferative retinopathy of prematurity. The preterm newborn was admitted and investigated for the ailments. The infant was hemodynamically stable, antibiotics for late-onset sepsis were ongoing, and striking rashes limited to palms and soles were noted [Figure 1]. Initial investigations for C-reactive protein, renal, and liver function tests were unremarkable. Blood/urine cultures for bacterial/fungal elements were negative. Titers for the congenital and perinatal infection etiology, including TORCHes, were non-reactive. Viral cultures were not available in our center. Maternal syphilis titers were non-reactive. Maternal antinuclear antibody was negative. The infant was managed for severe thrombocytopenia with serial platelet transfusions, optimized enteral nutrition, and retinal intervention of laser photocoagulation.

A petechial rash on the palmar surface of a preterm newborn.
Figure 1:
A petechial rash on the palmar surface of a preterm newborn.

The birth hospitalization of the male infant was for the vaginal premature birth at 28 weeks of gestation and 930 g, appropriate for gestation. He was cared for respiratory distress syndrome and possible sepsis. At 4–6 weeks of age, the newborn was detected for advanced retinopathy and severe thrombocytopenia (<10,000 mm3) and hence referred for tertiary care management. At presentation, the rashes in the dark-skinned infant raised suspicion for septic emboli, Janeway lesions, or Osler’s nodes. Blanchable lesions suggested an alternate diagnosis than petechiae. Clinical or laboratory features supportive of sepsis were low. Therefore, suspicion of septic emboli was low. Janeway lesions (erythematous non-tender macules) or Osler’s nodes (tender but dissimilar morphology) were ruled out as echocardiography ruled out infective endocarditis. The ductus arteriosus had closed. The magnified dermatoscopy images clarified the rashes’ morphology as irregularly shaped macules, consistent with petechial hemorrhage or a small capillary bleed. These rashes faded promptly on the palms and soles. The dark skin of the newborn might likely have prevented the visualization of rashes on the other parts of the body. The etiology of severe thrombocytopenia was puzzling after a negative search for fungal sepsis/urinary tract infection and venous thrombosis (inferior vena cava and renal vessels). Normal maternal platelet counts ruled out autoimmune thrombocytopenia. Severe thrombocytopenia (<10,000/mm3) was empirically managed by infusing 2 g/kg immunoglobulins for an undetected immune disorder, possibly neonatal immune thrombocytopenia purpura or antibodies developed in response to random donor platelets transfusions.

The uncontrolled fibroproliferative retinopathy in the index preterm newborn infant had grave concerns. The newborn infant was initially injected with anti-vascular endothelial growth factor (VEGF) therapy (anti-VEGF; Ranibizumab) bilaterally. In addition, multiple sessions of laser photocoagulation were attempted to control the progressive fibroproliferative retinopathy. The frequency of ophthalmic interventions and platelet transfusions was worrisome. These interventions were halted with the empirical infusion of intravenous immunoglobulins for possible immune-mediated thrombocytopenia. This had dual benefits: A prompt rise in platelet counts (>1 lakh/mm3) after 3 days of intravenous immunoglobulin and stabilization of retinal proliferation. This effect of intravenous immunoglobulins-mediated platelet count stabilization has been reported rarely. The manuscript aligns with another report, where platelet transfusions were therapeutic for progressive fibroproliferative disease.[1] Furthermore, in tandem with published literature, the underlying thrombocytopenia is known to exacerbate extensive anteroposterior retinopathy, and elevating platelet counts may benefit.[2-5] The newborn was discharged at a postmenstrual gestation of 41 weeks and recorded a discharge weight of 2200 g.

The association of low platelets and retinopathy of prematurity is currently under investigation.[1-5] Initial investigations explored the relationship between lower platelet counts in the 1st week of life after premature births and subsequent onset of retinopathy of prematurity requiring intervention. However, our report aligned with a recent investigation associating low platelets after 30 weeks postmenstrual age with a worsening effect on retinopathy of prematurity.[3] Platelets as VEGF scavengers limit the proliferative phase in retinopathy of prematurity. The authors present a unique case from low-resource settings linking immune thrombocytopenia with advanced retinopathy and a therapeutic effect on fibroproliferative retinopathy with the rise in platelet counts. The immediate stabilization of fibroproliferative retinopathy in the presence of thrombocytopenia needs to be studied more elaboratively in further studies. The case management illustrates the benefits of aggressive management of thrombocytopenia in preterm newborns with advanced retinopathy of prematurity.

Author contribution

CK: Wrote the initial manuscript; SK: Gave critical inputs; Both authors approved the final manuscript.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Financial support and sponsorship

Nil.

References

  1. , , , , , , et al. Do platelets have a role in the pathogenesis of aggressive posterior retinopathy of prematurity? Retina. 2010;30:S20-3.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Association of platelet deficiency with severe retinopathy of prematurity: A review. Acta Paediatr. 2022;111:2056-70.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , , et al. Thrombocytopenia is associated with severe retinopathy of prematurity. JCI Insight. 2018;3:e99448.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . Impact of platelet count in retinopathy of prematurity. Turk J Ophthalmol. 2020;50:351-5.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , , . Thrombocytopenia and retinopathy of prematurity. J AAPOS. 2011;15:e3-4.
    [CrossRef] [Google Scholar]

Fulltext Views
668

PDF downloads
6
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections