الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Immune thrombocytopenic purpura is a relatively conventional hematologic state, but did not achieve a blood community with regard to the disadvantages of treatment. Childhood ITP is generally a benign self-limited disease that occurs in healthy children, and often virus infection or immunization is preceded. The International Working group (IWG) of experts established a platelet count less than 100,000/mm3 as the threshold for diagnosis. According to the IWG, ITP has been classified as newly diagnosed or acute (within 3 months from diagnosis), persistent (between 3 and 12 months) and chronic (lasting for more than 12 months). Female gender, older age at presentation, absence of previous infection or vaccination, insidious onset, higher platelet count at presentation, positivity for antinuclear antibodies (ANA), and unresponsiveness to a single dose of intravenous human immunoglobulins are considered the predictors of the chronic course of the disease. The platelet count is not directly related with the bleeding risk and the clinical manifestations of ITP.Signs and symptoms vary widely; many patients have either no symptoms or minimal bruising, whereas others experience serious bleeding, which may include gastrointestinal, extensive skin and mucosal hemorrhage, or rarely intracranial hemorrhage. Diagnosis of ITP is made clinically by ruled out another cause of thrombocytopenia, the lack of splenomegaly, and by finding normal or increased megakaryopoeisis on bone marrow examination. Since the immunity of this disorder has been described, many platelet antibody tests have been evaluated for the diagnosis of ITP. Despite the enthusiasm for the measurement of platelet-related Ig (PAIg) in the 1970s, subsequent studies have shown that the measurement of PAIg is sensitive in many forms, but non-specific for the diagnosis of immune thrombocytopenia. It is shown to be PAIg tests to determine the mode of antibody interaction with platelets cannot be performed together (antigen-specific versus non-specific binding). The inability of PAIg to identify antigenic direct monoclonal antibody immobilization of platelet antigens (MAIPA) assays. MAIPA was very good at distinguishing between immune thrombocytopenia and non-immune thrombocytopenia. Autoimmune thyroiditis is one of the most common among autoimmune diseases. Autoimmune thyroiditis is multifactorial with the contribution of genetic and environmental factors. Much information has been published about genetic predisposition to autoimmune thyroiditis in humans. On the other hand, there are limited data on environmental agents that may induce autoimmunity in genetically predisposed hosts. Substantial evidence has accumulated on the pathogenesis and predisposing factors as a result of advances in immunology and genetics that have helped us to elucidate the complexities of thyroid autoimmune. In addition, epidemiology of autoimmune thyroiditis in children. Patients and Methods This is a prospective case -control study which had been carried out in the pediatric hematology Unit, Tanta university hospital and clinical pathology department, Faculty of Medicine, Tanta University, 50 pediatric ITP patients and 50 healthy children as control group had been enrolled in this study. Study Design: Duration of the research was: from March 2021 to February 2022. Adherence to ethical standards: an informed consent had been taken from parents of each patient included in the study. • Parents of each patient had been informed about all steps in our study. • The privacy of participants and confidentiality of data had been guaranteed by the research candidate during various phases of the study. All patients had a code number, and all patients’ data had been used for scientific purposes only. • The study had been approved by Research Ethics Committee of Faculty of Medicine, Tanta University. Inclusion criteria: Age of ITP diagnosis <18 years, diagnosis of ITP according with the IWG guidelines, and at least one year of follow-up. Exclusion criteria: Patient with 2ry ITP due to infections as (viral hepatitis B virus, hepatitis C virus and human immunodeficiency virus) had been excluded from the study. This prospective control study had been carried out on 50 children with newly diagnosed primary immune thrombocytopenia (ITP group). They presented with isolated peripheral thrombocytopenia with or without external or internal bleeding. Also, 50 apparently healthy children, age and sex matched with the patients, were included as control group. All children in the control group had no history of bleeding tendency, and normal platelet count in their complete blood count. Sampling Protocol: A venous blood sample had been withdrawn from each child by a sterile venipuncture; 1ml whole blood had been collected on EDTA used for platelet count estimation with automated hematology cell counter. The remainder of the sample had been collected in a plain tube and allowed to clot at 37°C. After centrifugation at 3,000 rpm for 10 min, the separated sera had been used for assessment of thyroid gland functions (free T3, free T4, and TSH, anti-thyroid peroxidase antibody, anti-thyroglobulin antibody) to exclude any thyroid dysfunctions for all cases and control. The remaining serum had been kept frozen at −20°C until assessment of, anti-platelet antibody, ANA and Anti ds DNA by ELISA method. All patients and controls in this study were subjected to the Following at time of diagnosis: i. Complete history taking. ii. Thorough clinical examination. iii. Investigations including: 1. Complete blood picture. 2. Bone Marrow Aspiration 3. Serum levels of ANA, anti-ds.DNA 4. Thyroid-stimulating hormone (TSH), free thyroxin (FT4), FT3 5. Anti-thyroid peroxidase antibodies (TPO), anti-thyroglobulin antibodies (TG) antibodies. 6. Antiplatelet antibody IV. Then patient had been followed clinically and laboratory for one year. Aim of the Work The aims of the study are to evaluate: 1. The prevalence of antithyroid antibodies (Anti-thyroid peroxidase antibody TPO and Antithyroglobulin antibody TG) in pediatric patients with ITP and their influence on treatment response. 2. The role of autoimmune thyroiditis as a prognostic factor for ITP in children. 3. The prevalence of thyroid dysfunction in pediatric patients with ITP. 4. The prevalence of antiplatelet antibodies, ANA, Anti-ds DNA in pediatric ITP. Results In this study, ITP group included 50 patient, 36(72%) of them were females and 14 (28%) were males with a median age of 11.0 years and control group included 50 healthy children, 26 (52%) of them were females and 24 (48%) were males with a median age of 7.3 years . female sex is statistically significant (p>0.001) The mean HB of ITP cases at time of presentation was 10.2±1.0 , that was statistically significant in comparison to the mean HB of the control group, which was 10.9±1.2 (p = 0.001) and according to indices MCV was not significant in patient group ,MCH was significant P>0.05 in patient group in relation with control group. The mean platelet count of ITP cases at time of presentation was 25200.0±9638.4/mm , that was statistically significant in comparison to the mean platelet count of the control group, which was 241140.0±61403.3 /mm. (p <0.001) The median TLC of ITP cases at time of presentation was 7000, that was statistically significant in comparison to the median TLC count of the control group, which was 9550 (p < 0.001), and according to its differentiation neutrophil and lymphocytic percentage were not statistically significant P>0.05 In ITP patient group, antiplatelet antibody (IgG) was statistically nonsignificant according to sex but in patients whose age more than 10 years antiplatelet antibody(IgG) was statistically significant as p < .001 in both male and female . Anti thyroglobin and Anti-peroxidase antibodies were statistically significant in the children with ITP than the control group as ( P <0 .001). ANA and Anti-ds DNA were statistically significant in the children with ITP than the control group as (P < 0.001). Antiplatelet was statistically significant in the children with ITP than the control group (P <0.001). After subgrouping the children with ITP into positive & negative antiplatelet antibody , Anti thyroglobin and Anti-peroxidase antibodies were statistically significant in the children with ITP with positive antiplatelet antibody P <0 .001. After subgrouping of ITP patient group into antiplatelet antibody positive and negative in relation to BMA it was statistically significant (Pvalue (0.029)), platelet count also was statistically significant as lower platelet count in antiplatelet antibody positive than antiplatelet antibody negative patient. In our study ,according to clinical course we can predict our patient to be acute around age 4yrs old (p1<0.001 (,to be persistent around age group 8yrs old (p2<0.001(and to be chronic around 13 years old(p3<0.001). but statistically non-significant according to sex in ITP patients subgroups. After subgrouping the children with ITP into acute & chronic and persistant groups according to clinical course of ITP patient . As regards the level of the following antibodies (antiplatelet, aTPo and aTg) in these groups, the difference between acute and chronic groups was statistically significant )P1<0.001(,also,the difference between chronic and persistent groups was statistically significant )p3<0.001 (. According to ITP subgroups (acute, persistent and chronic )There was no statistical significant differences in the levels of the studied thyroid function , platelet count and Hb (P >0 .05) After subgrouping the children with ITP into acute & chronic and persistant groups. As regards the level of the following antibodies (antiplatelet, aTPo and aTg) the relation between their clinical course and antibodies positivity in these groups, it was statistically significant between acute and chronic groups )P1<0.001(,and statistically significant between chronic and persistent groups )p3<0.001 (. ITP patient with positive antiplatelet AB, showing more resistance according to effective medications with good response on Eltrombopag olamine in comparison to ITP patients with negative antiplatelet AB. (p <0 .001) As regard effective medication of ITP two patients who were antiplatelet antibody positive received (IVIG) 400mg /kg/dose for 5 doses with no markable improvement so, shifted on Eltrombopag olamine. ITP patient with positive Anti thyroglobin and Anti-peroxidase antibodies , showing more resistance According to effective medications with good response on Eltrombopag olamine in comparison to ITP patients with negative antithyroglobulin and antipyroxidase AB. (p <0 .001) ITP patient with positive Anti thyroglobin and Anti-peroxidase antibodies , showing more resistance According to effective medications with good response on Eltrombopag olamine in comparison to ITP patients with negative antithyroglobulin and antipyroxidase AB. (p <0 .001) According to effective medication in comparison between Eltrombopag olamine and steroids as regards thyroid functions and CBC were statistically insignificant. except with MCH that was statistically significant . In our study , the correlation between platelet count in pediatric ITP patient , age, thyroid function ,hemoglobin and TLC count was statistically nonsignificant as p <0.001.