REFRACTORY ITP IN ART-NAIVE PLHIV

Immune/Idiopathic Thrombocytopenic Purpura (ITP) is the main cause of thrombocytopenia in people living with HIV/Aids (PLHIV) and may occur at any stage of infection. In the pre-HAART (highly active antiretroviral therapy) era, its incidence reached up to 30%, decreasing in recent years. It can be the initial manifestation in up to 10% of HIV cases and is considered a marker of advanced disease. In addition, thrombocytopenia remains an important complication, as it increases the risk of severe and fatal bleeding events and other complications. Its exact pathogenesis remains unknown, but the association between HIV infection and ITP has already been confirmed by observational studies. This case report describes a 52-year-old cisgender man recently diagnosed with HIV/Aids (CD4: 59 cells/mm³; VL: 2,450,000 copies/mL). He was admitted with 102,000 platelets/mm³ and no alterations in other cell lines. About 10 days after initiation of dual therapy with lamivudine/dolutegravir and primary prophylaxis with SMX/TMP, a new collection showed 15,000 platelets/mm³, confirmed with citrate tube (9,000/mm³). Initially asymptomatic, he progressed with ecchymoses, hematuria, and hemorrhoidal bleeding. He was hospitalized and received intravenous methylprednisolone (IV), under the hypothesis of ITP secondary to HIV, after exclusion of other etiologies. He showed improvement (163,000 platelets) and was discharged on oral prednisone 20 mg/day. During follow-up, he presented new episodes of thrombocytopenia below 50,000/mm³ and required two additional cycles of IV methylprednisolone pulse therapy. Platelet counts remained stable only with prednisone at 1.5 mg/kg, consistently below 100,000/mm³. After five months of corticosteroid treatment without satisfactory response and after extensive diagnostic investigation, Eltrombopag Olamine, a thrombopoietin receptor agonist, was initiated, resulting in clinical improvement and tapering of corticosteroids. A retrospective study shows that more than one-third of PLHIV with ITP do not respond to treatment (HAART + glucocorticoids as first line). In these cases, especially in persistent and chronic ITP, response rates are low and recurrence rates high, findings similar to the case reported. This case highlights the importance of expanding the therapeutic arsenal within the public health system for cases refractory to first-line medications provided by SUS, and of training healthcare teams on available therapeutic options through high-cost dispensing units.