Diagnosis and Management of Inherited Thrombocytopenias

 

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Abstract

The number of recognized causes of inherited thrombocytopenias has grown in the past 10 years and there are now more than 18 thrombocytopenic disorders with characterized genetic mutations. Moreover, the pathogenic mechanisms of many forms of inherited thrombocytopenia have been identified and prognosis of different disorders, ranging from unfavorable to very good, has been defined. In addition, for some inherited thrombocytopenias, therapies are now available to improve both survival and quality of life for persons with these conditions. Therefore, it is important to recognize when a low platelet count reflects an inherited disorder, and establish a correct diagnosis; however, this remains a challenge because documented evidences about these diseases are scarce. In this review, we address how to diagnose inherited thrombocytopenia, how to differentiate these conditions from immune thrombocytopenia, present a new and simple diagnostic algorithm, and discuss the different therapeutic options. We also emphasize that further research on these disorders is needed, as about half of patients with inherited thrombocytopenias have a disease that is not yet characterized.

• References

• 1 Balduini CL, Savoia A. Genetics of familial forms of thrombocytopenia. Hum Genet 2012; 131 (12) 1821-1832
  CrossrefPubMedGoogle Scholar
• 2 Seri M, Cusano R, Gangarossa S , et al. The May-Heggllin/Fechtner Syndrome Consortium. Mutations in MYH9 result in the May-Hegglin anomaly, and Fechtner and Sebastian syndromes. Nat Genet 2000; 26 (1) 103-105
  CrossrefPubMedGoogle Scholar
• 3 Seri M, Pecci A, Di Bari F , et al. MYH9-related disease: May-Hegglin anomaly, Sebastian syndrome, Fechtner syndrome, and Epstein syndrome are not distinct entities but represent a variable expression of a single illness. Medicine (Baltimore) 2003; 82 (3) 203-215
  CrossrefPubMedGoogle Scholar
• 4 Jackson SC, Sinclair GD, Cloutier S, Duan Z, Rand ML, Poon MC. The Montreal platelet syndrome kindred has type 2B von Willebrand disease with the VWF V1316M mutation. Blood 2009; 113 (14) 3348-3351
  CrossrefPubMedGoogle Scholar
• 5 Rees DC, Iolascon A, Carella M , et al. Stomatocytic haemolysis and macrothrombocytopenia (Mediterranean stomatocytosis/macrothrombocytopenia) is the haematological presentation of phytosterolaemia. Br J Haematol 2005; 130 (2) 297-309
  CrossrefPubMedGoogle Scholar
• 6 Savoia A, Balduini CL, Savino M , et al. Autosomal dominant macrothrombocytopenia in Italy is most frequently a type of heterozygous Bernard-Soulier syndrome. Blood 2001; 97 (5) 1330-1335
  CrossrefPubMedGoogle Scholar
• 7 Noris P, Pecci A, Di Bari F , et al. Application of a diagnostic algorithm for inherited thrombocytopenias to 46 consecutive patients. Haematologica 2004; 89 (10) 1219-1225
  PubMedGoogle Scholar
• 8 Biino G, Balduini CL, Casula L , et al. Analysis of 12,517 inhabitants of a Sardinian geographic isolate reveals that predispositions to thrombocytopenia and thrombocytosis are inherited traits. Haematologica 2011; 96 (1) 96-101
  CrossrefPubMedGoogle Scholar
• 9 Biino G, Gasparini P, D'Adamo P , et al. Influence of age, sex and ethnicity on platelet count in five Italian geographic isolates: mild thrombocytopenia may be physiological. Br J Haematol 2012; 157 (3) 384-387
  CrossrefPubMedGoogle Scholar
• 10 Santimone I, Di Castelnuovo A, De Curtis A , et al. MOLI-SANI Project Investigators. White blood cell count, sex and age are major determinants of heterogeneity of platelet indices in an adult general population: results from the MOLI-SANI project. Haematologica 2011; 96 (8) 1180-1188
  CrossrefPubMedGoogle Scholar
• 11 Bader-Meunier B, Proulle V, Trichet C , et al. Misdiagnosis of chronic thrombocytopenia in childhood. J Pediatr Hematol Oncol 2003; 25 (7) 548-552
  CrossrefPubMedGoogle Scholar
• 12 Geddis AE, Balduini CL. Diagnosis of immune thrombocytopenic purpura in children. Curr Opin Hematol 2007; 14 (5) 520-525
  CrossrefPubMedGoogle Scholar
• 13 Balduini CL, Pecci A, Savoia A. Recent advances in the understanding and management of MYH9-related inherited thrombocytopenias. Br J Haematol 2011; 154 (2) 161-174
  CrossrefPubMedGoogle Scholar
• 14 Notarangelo LD, Miao CH, Ochs HD. Wiskott-Aldrich syndrome. Curr Opin Hematol 2008; 15 (1) 30-36
  CrossrefPubMedGoogle Scholar
• 15 Ciovacco WA, Raskind WH, Kacena MA. Human phenotypes associated with GATA-1 mutations. Gene 2008; 427 (1-2) 1-6
  CrossrefPubMedGoogle Scholar
• 16 Balduini CL, Pecci A, Loffredo G , et al. Effects of the R216Q mutation of GATA-1 on erythropoiesis and megakaryocytopoiesis. Thromb Haemost 2004; 91 (1) 129-140
  PubMedGoogle Scholar
• 17 Liew E, Owen C. Familial myelodysplastic syndromes: a review of the literature. Haematologica 2011; 96 (10) 1536-1542
  CrossrefPubMedGoogle Scholar
• 18 Noris P, Perrotta S, Seri M , et al. Mutations in ANKRD26 are responsible for a frequent form of inherited thrombocytopenia: analysis of 78 patients from 21 families. Blood 2011; 117 (24) 6673-6680
  CrossrefPubMedGoogle Scholar
• 19 Albers CA, Paul DS, Schulze H , et al. Compound inheritance of a low-frequency regulatory SNP and a rare null mutation in exon-junction complex subunit RBM8A causes TAR syndrome. Nat Genet 2012; 44 (4) 435-439 , S1–S2
  CrossrefPubMedGoogle Scholar
• 20 Castillo-Caro P, Dhanraj S, Haut P, Robertson K, Dror Y, Sharathkumar AA. Proximal radio-ulnar synostosis with bone marrow failure syndrome in an infant without a HOXA11 mutation. J Pediatr Hematol Oncol 2010; 32 (6) 479-485
  CrossrefPubMedGoogle Scholar
• 21 Pecci A, Biino G, Fierro T , et al. Italian Registry for MYH9-releated diseases. Alteration of liver enzymes is a feature of the MYH9-related disease syndrome. PLoS ONE 2012; 7 (4) e35986
  CrossrefPubMedGoogle Scholar
• 22 Savoia A, De Rocco D, Panza E , et al. Heavy chain myosin 9-related disease (MYH9 -RD): neutrophil inclusions of myosin-9 as a pathognomonic sign of the disorder. Thromb Haemost 2010; 103 (4) 826-832
  Article in Thieme ConnectPubMedGoogle Scholar
• 23 Noris P, Klersy C, Zecca M , et al. Platelet size distinguishes between inherited macrothrombocytopenias and immune thrombocytopenia. J Thromb Haemost 2009; 7 (12) 2131-2136
  CrossrefPubMedGoogle Scholar
• 24 Balduini CL, Cattaneo M, Fabris F , et al. Italian Gruppo di Studio delle Piastrine. Inherited thrombocytopenias: a proposed diagnostic algorithm from the Italian Gruppo di Studio delle Piastrine. Haematologica 2003; 88 (5) 582-592
  PubMedGoogle Scholar
• 25 Glembotsky AC, Marta RF, Pecci A , et al. International collaboration as a tool for diagnosis of patients with inherited thrombocytopenia in the setting of a developing country. J Thromb Haemost 2012; 10 (8) 1653-1661
  CrossrefPubMedGoogle Scholar
• 26 Raccuglia G. Gray platelet syndrome. A variety of qualitative platelet disorder. Am J Med 1971; 51 (6) 818-828
  CrossrefPubMedGoogle Scholar
• 27 Noris P, Spedini P, Belletti S, Magrini U, Balduini CL. Thrombocytopenia, giant platelets, and leukocyte inclusion bodies (May-Hegglin anomaly): clinical and laboratory findings. Am J Med 1998; 104 (4) 355-360
  CrossrefPubMedGoogle Scholar
• 28 Othman M. Platelet-type von Willebrand disease: a rare, often misdiagnosed and underdiagnosed bleeding disorder. Semin Thromb Hemost 2011; 37 (5) 464-469
  Article in Thieme ConnectPubMedGoogle Scholar
• 29 Savoia A, Pastore A, De Rocco D , et al. Clinical and genetic aspects of Bernard-Soulier syndrome: searching for genotype/phenotype correlations. Haematologica 2011; 96 (3) 417-423
  CrossrefPubMedGoogle Scholar
• 30 Noris P, Perrotta S, Bottega R , et al. Clinical and laboratory features of 103 patients from 42 Italian families with inherited thrombocytopenia derived from the monoallelic Ala156Val mutation of GPIbα (Bolzano mutation). Haematologica 2012; 97 (1) 82-88
  CrossrefPubMedGoogle Scholar
• 31 Nurden AT, Pillois X, Fiore M, Heilig R, Nurden P. Glanzmann thrombasthenia-like syndromes associated with Macrothrombocytopenias and mutations in the genes encoding the αIIbβ3 integrin. Semin Thromb Hemost 2011; 37 (6) 698-706
  Article in Thieme ConnectPubMedGoogle Scholar
• 32 Kunishima S, Kobayashi R, Itoh TJ, Hamaguchi M, Saito H. Mutation of the beta1-tubulin gene associated with congenital macrothrombocytopenia affecting microtubule assembly. Blood 2009; 113 (2) 458-461
  PubMedGoogle Scholar
• 33 Pecci A, Panza E, Pujol-Moix N , et al. Position of nonmuscle myosin heavy chain IIA (NMMHC-IIA) mutations predicts the natural history of MYH9-related disease. Hum Mutat 2008; 29 (3) 409-417
  CrossrefPubMedGoogle Scholar
• 34 George JN, Shattil SJ. The clinical importance of acquired abnormalities of platelet function. N Engl J Med 1991; 324 (1) 27-39
  CrossrefPubMedGoogle Scholar
• 35 Heller PG, Pecci A, Glembotsky AC , et al. Unexplained recurrent venous thrombosis in a patient with MYH9-related disease. Platelets 2006; 17 (4) 274-275
  CrossrefPubMedGoogle Scholar
• 36 Peaceman AM, Katz AR, Laville M. Bernard-Soulier syndrome complicating pregnancy: a case report. Obstet Gynecol 1989; 73 (3 Pt 2) 457-459
  PubMedGoogle Scholar
• 37 Ballmaier M, Germeshausen M. Congenital amegakaryocytic thrombocytopenia: clinical presentation, diagnosis, and treatment. Semin Thromb Hemost 2011; 37 (6) 673-681
  Article in Thieme ConnectPubMedGoogle Scholar
• 38 Moratto D, Giliani S, Bonfim C , et al. Long-term outcome and lineage-specific chimerism in 194 patients with Wiskott-Aldrich syndrome treated by hematopoietic cell transplantation in the period 1980-2009: an international collaborative study. Blood 2011; 118 (6) 1675-1684
  CrossrefPubMedGoogle Scholar
• 39 Locatelli F, Rossi G, Balduini C. Hematopoietic stem-cell transplantation for the Bernard-Soulier syndrome. Ann Intern Med 2003; 138 (1) 79
  PubMedGoogle Scholar
• 40 Rieger C, Rank A, Fiegl M , et al. Allogeneic stem cell transplantation as a new treatment option for patients with severe Bernard-Soulier Syndrome. Thromb Haemost 2006; 95 (1) 190-191
  PubMedGoogle Scholar
• 41 Kuter DJ. New thrombopoietic growth factors. Blood 2007; 109 (11) 4607-4616
  CrossrefPubMedGoogle Scholar
• 42 Pecci A, Gresele P, Klersy C , et al. Eltrombopag for the treatment of the inherited thrombocytopenia deriving from MYH9 mutations. Blood 2010; 116 (26) 5832-5837
  CrossrefPubMedGoogle Scholar
• 43 Pecci A, Barozzi S, d'Amico S, Balduini CL. Short-term eltrombopag for surgical preparation of a patient with inherited thrombocytopenia deriving from MYH9 mutation. Thromb Haemost 2012; 107 (6) 1188-1189
  Article in Thieme ConnectPubMedGoogle Scholar
• 44 Kuter DJ, Mufti GJ, Bain BJ, Hasserjian RP, Davis W, Rutstein M. Evaluation of bone marrow reticulin formation in chronic immune thrombocytopenia patients treated with romiplostim. Blood 2009; 114 (18) 3748-3756
  CrossrefPubMedGoogle Scholar
• 45 Léon C, Evert K, Dombrowski F , et al. Romiplostim administration shows reduced megakaryocyte response-capacity and increased myelofibrosis in a mouse model of MYH9-RD. Blood 2012; 119 (14) 3333-3341
  CrossrefPubMedGoogle Scholar
• 46 Mullen CA, Anderson KD, Blaese RM. Splenectomy and/or bone marrow transplantation in the management of the Wiskott-Aldrich syndrome: long-term follow-up of 62 cases. Blood 1993; 82 (10) 2961-2966
  PubMedGoogle Scholar
• 47 Albert MH, Bittner TC, Nonoyama S , et al. X-linked thrombocytopenia (XLT) due to WAS mutations: clinical characteristics, long-term outcome, and treatment options. Blood 2010; 115 (16) 3231-3238
  CrossrefPubMedGoogle Scholar
• 48 Conley ME, Saragoussi D, Notarangelo L, Etzioni A, Casanova JL. PAGID; ESID. An international study examining therapeutic options used in treatment of Wiskott-Aldrich syndrome. Clin Immunol 2003; 109 (3) 272-277
  CrossrefPubMedGoogle Scholar
• 49 Balduini CL, Noris P, Belletti S, Spedini P, Gamba G. In vitro and in vivo effects of desmopressin on platelet function. Haematologica 1999; 84 (10) 891-896
  PubMedGoogle Scholar
• 50 Tosetto A, Balduini CL, Cattaneo M , et al. Italian Society for Haemostasis and Thrombosis. Management of bleeding and of invasive procedures in patients with platelet disorders and/or thrombocytopenia: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2009; 124 (5) e13-e18
  CrossrefPubMedGoogle Scholar
• 51 Mattina T, Perrotta CS, Grossfeld P. Jacobsen syndrome. Orphanet J Rare Dis 2009; 4: 9
  CrossrefPubMedGoogle Scholar
• 52 Di Paola J, Johnson J. Thrombocytopenias due to gray platelet syndrome or THC2 mutations. Semin Thromb Hemost 2011; 37 (6) 690-697
  Article in Thieme ConnectPubMedGoogle Scholar
• 53 Hamilton A, Ozelo M, Leggo J , et al. Frequency of platelet type versus type 2B von Willebrand disease. An international registry-based study. Thromb Haemost 2011; 105 (3) 501-508
  Article in Thieme ConnectPubMedGoogle Scholar
• 54 Nurden P, Debili N, Coupry I , et al. Thrombocytopenia resulting from mutations in filamin A can be expressed as an isolated syndrome. Blood 2011; 118 (22) 5928-5937
  CrossrefPubMedGoogle Scholar
• 55 Gresele P, Falcinelli E, Giannini S , et al. Dominant inheritance of a novel integrin beta3 mutation associated with a hereditary macrothrombocytopenia and platelet dysfunction in two Italian families. Haematologica 2009; 94 (5) 663-669
  CrossrefPubMedGoogle Scholar
• 56 Geddis AE. Congenital amegakaryocytic thrombocytopenia. Pediatr Blood Cancer 2011; 57 (2) 199-203
  CrossrefPubMedGoogle Scholar
• 57 Pippucci T, Savoia A, Perrotta S , et al. Mutations in the 5′ UTR of ANKRD26, the ankirin repeat domain 26 gene, cause an autosomal-dominant form of inherited thrombocytopenia, THC2. Am J Hum Genet 2011; 88 (1) 115-120
  CrossrefPubMedGoogle Scholar
• 58 Castillo-Caro P, Dhanraj S, Haut P, Robertson K, Dror Y, Sharathkumar AA. Proximal radio-ulnar synostosis with bone marrow failure syndrome in an infant without a HOXA11 mutation. J Pediatr Hematol Oncol 2010; 32 (6) 479-485
  CrossrefPubMedGoogle Scholar
• 59 Morison IM, Cramer Bordé EM, Cheesman EJ , et al. A mutation of human cytochrome c enhances the intrinsic apoptotic pathway but causes only thrombocytopenia. Nat Genet 2008; 40 (4) 387-389
  CrossrefPubMedGoogle Scholar