Resistant Idiopathic Thrombocytopenic Purpura - Treatment with Rituximab.

Introduction: Idiopathic thrombocytopenic purpura (ITP) is a disorder characterized by thrombocytopenia and mucosal bleeding. Treatment of ITP is sometimes ineffective due to the fact that these patients develop chronic disease, refractory to any conventional therapeutic option.

Aim: We present 3 cases of relapsed and resistant ITP, with major bleeding problems and threatening to life low platelet count for a long period, successfully treated with rituximab, the anti CD20 antibody, with stable platelet count and no bleeding symptoms since then.

Case 1: M.S (D.O.B: 1944) diagnosed in 1999. She first underwent a treatment with steroids, which showed minor response with persistent bleeding episodes and impairment of her diabetes mellitus. During her treatment with steroids she was extra treated with danazol, with no beneficial effect on her. After 6 months the patient received cyclosporine with no affect. After that the patient received IVIG for 6 months. Over this period her platelet count never exceeded 50x10⁹/L and that count lasting for 2 weeks. She underwent a splenectomy, which stabilized her platelets up to 80x10⁹/L for 3 months only. When her platelet count reached 25x10⁹/L, 4 doses of rituximab were applied in weekly intervals followed with 2 doses of rituximab applied every month. The satisfactory response with platelets over 100x10⁹/L was obtained. The platelets were over 200x10⁹/L after the third month. For the period of 2 years now she didn’t need any medical care for the ITP.

Case 2: T.M (D.O.B: 1954) diagnosed with CLL since 1997. He was under remission when he came on November 2004 with very low platelet (3x10⁹/L), high fever and major gastrointestinal bleeding. After the fever management, high doses of corticosteroids were administrated for the control of platelets count, followed by high dose IVIG with no control of the situation. His state has remained crucial for a 4 weeks interval since gastrointestinal bleeding was not reduced and the platelet count was fixed at a minimal amount (1–3x10⁹). Then we decided to administrate rituximab. After the first treatment with rituximab the platelets seemed to stabilize and after the second infusion the platelet count was 40x10⁹/L. The patient received 4 doses of rituximab in weekly intervals, and his platelets rised above 100x10⁹ followed by 4 doses applied every month and since then he receives one dose every 2 months with very good results (platelet count 200x10⁹).

Case 3: M.L (D.O.B: 1942) diagnosed with ITP since 2003. Initial steroid treatment for 14 months stopped the bleeding but was replaced with IVIG due to side effects of corticosteroids, (2 severe episodes of high fever and pulmonary infection and hyperglukemia). IVIG infusion managed to control the platelet count over 50x10⁹/L but for the short period of time of 14–18 days. After that 4 doses of rituximab were administrated every week with the excellent result of 120x10⁹/L even after the first dose. At the end of 4 doses the patient had over 250x10⁹/L platelets and for 8 months now he needs no treatment for the ITP.

Conclusion: Our findings suggest that rituximab is a strong and potential treatment in refractory and relapsed cases of ITP.