Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease in which most patients have antibodies to specific membrane glycoprotein's on platelets. The incidence in adults is about 33/1,000,000 [96
]of which about 10/1,000,000 become refractory. Spontaneous remission is uncommon in adults. The 5-year mortality rate is significantly elevated in adults over the age of 60 (47.8%) versus those below 40 years of age (2.2%), respectively. The most serious complication is hemorrhage of which intracranial hemorrhage is the most significant.
Vitamin D has been shown to improve outcomes and prevent some autoimmune diseases if taken early in life as discussed previously in the paper.
Treatment of ITP usually includes medications such as corticosteroids, splenectomy danazol, and various immune suppressant therapies [97
]. The use of vitamin D3
in ITP has not been described in the literature.
This example describes a patient who had refractory ITP who has been treated in the past with a splenectomy, danazol, and prednisone rescue during intercurrent illness. A review of the history of this case revealed a 48-year-old female who was found to have a very low platelet count in 1998, which remained persistent over time. After consultation with a hematologist, the diagnosis of ITP was made. Her platelets continued to drop so she had a splenectomy, which improved her platelet count, but it never achieved normal. Despite the use of danazol, her platelet count never normalized. She had frequent episodes of low platelets as low as 8
with intercurrent illnesses such as colds or flus. In 2006 she was found to have an inadequate level of 25(OH)D of 65
nmol/L. Her platelet count at that time was 8
after a viral illness. She was treated successfully with a tapering dose of Prednisone. She was started on vitamin D3
IU daily after this episode and during the next two years while she was on this dose she did not have any flus or colds and her platelet count never fell below 44
and was usually from 70 to 80
. This was quite out of the normal for her since she had at least one low episode a year. After being on this dose for two years, a neighbor in her building where she resided suggested that she was going to become toxic on this dose and she stopped her vitamin D. About three months later, she again had an upper respiratory infection (URI) and her platelets dropped only to 50
and she was started on prednisone with recovery of her platelets to 140
. She was seen after this, and it was recommended that she resume her vitamin D3
at a higher dose of 4000
IU daily. She was feeling quite well, and her platelets remained above 70 and continued to rise so she discontinued her danazol. Again, she had no further episodes of flu or colds for the next two years and her platelets did not drop below 70. Her vitamin D level on this dose was 88
nmol/L after 4 months. She phoned one day that she was sick with a URI, and it was suggested that she take 10,000
IU of vitamin D for a 3 days and have her platelets checked. She had her platelets checked after being on this dose for two days, and they were in the normal range much higher than they had been for years. The platelet count was 248
. Her vitamin D level was 99
nmol/L at this time. She continues on the 4000
IU vitamin D, and she continues off the danazol and remains well. Her latest platelet count was 318
This case presents a significant response to vitamin D3
in ITP. As well, it demonstrates a recurrent failure with lack of vitamin D and restoration of a normal platelet count on a higher dosing of vitamin D3
, which did not result in toxicity. The vitamin D3
rescue with 10,000
IU of vitamin D3
appeared to result in a similar response as that of prednisone used in past treatments over the years. ITP has been shown to have spontaneous remission in some people; however, it is uncommon in older patients. Is it possible that restoration of vitamin D levels results in some of these cases of spontaneous resolution? At this time this is not known. Restoring vitamin D to a level that is safe appears to be sensible supportive therapy.
Restoration of adequate platelets has never been demonstrated with repletion of inadequate vitamin D levels in the literature. Certainly in this example, vitamin D3 restoring reasonable platelet levels and reducing the number of infections is most fascinating. The reduction in platelet levels with removal of vitamin D3 with restoration of normal levels with an increased dose of vitamin D3, as well as rescue with higher levels of vitamin D3, is furthermore more intriguing. More studies would be warranted to demonstrate the benefit of adequate 25(OH)D levels in ITP.