摘要
第一部分人巨细胞病毒感染与特发性血小板减少性紫癜患儿细胞免疫功能及治疗转归的临床研究
目的探讨人类巨细胞病毒(HCMV)感染与儿童特发性血小板减少性紫癜(ITP)发病、疗效及预后的相关性,为临床更合理有效治疗ITP提供部分参考。
方法用ELISA法和流式细胞仪分别检测患儿血清HCMV抗体及外周血淋巴细胞亚群,比较2002年1月-2006年12月在本院儿科就诊的230例ITP患儿及对照组200例同期急性上呼吸道感染患儿的HCMV感染率及细胞免疫状态。进一步将ITP患儿按有无HCMV感染分为HCMV感染组和非感染组,比较二组患儿细胞免疫状态、近期(二周)治疗效果、远期(大于6个月)疾病转归之间的关系。
结果230例ITP患儿中,伴HCMV感染者88例(38.26%),淋巴细胞亚群比例异常165例(71.74%);同期200例急性上呼吸道感染患儿中HCMV感染22例(11.0%),淋巴细胞亚群比例异常36例(18.0%),二组比较有显著统计学差异(P＜0.01,P＜0.01)。初诊时HCMV感染组细胞免疫异常74例(84.09%),非感染组91例(64.08%);6个月后,HCMV感染组检测到细胞免疫异常24例(27.27%),非感染组5例(3.52%)。二组比较有显著统计学差异(P＜0.01)。HCMV感染组与非感染组近期治疗效果无统计学差异(P＞0.05),HCMV感染组中35例(39.78%)病程超过6个月,而非感染组中24例(16.90%)病程超过6个月,二组比较有显著统计学差异(P＜0.01)。抗HCMV治疗组54例,病程超过6个月15例(27.78%),常规治疗组34例,病程超过6个月20例(58.82%),二组相比有显著统计学差异(P＜0.01)。
结论HCMV感染诱发的细胞免疫异常是儿童ITP发病及病程迁延的重要因素。抗HCMV治疗对于ITP的恢复有明确效果,且副作用少,患儿耐受性好。
第二部分儿童AITP治疗前后CD4~+CD25~(High)Foxp3~+Treg细胞与Foxp3基因表达的变化
目的通过检测静注丙种球蛋白、肾上腺皮质激素(简称激素)治疗前后儿童急性特发性血小板减少性紫癜(AITP)CD4~+CD25~(High)Foxp3~+Treg细胞比例及Foxp3基因表达的变化,探讨CD4~+CD25~(High)Foxp3~+Treg细胞在AITP发病中的作用及对静注丙种球蛋白、激素治疗的效应关系。
方法流式细胞仪检测AITP患儿治疗前后CD4~+CD25~(High)Foxp3~+Treg细胞比例变化,RT-PCR法检测外周血单个核细胞中Foxp3mRNA的表达。
结果AITP患儿治疗前CD4~+CD25~(High)Foxp3~+Treg细胞比例与Foxp3基因表达水平明显低于正常对照组(P＜0.01);单用激素或联用激素和静注丙种球蛋白治疗后AITP患儿CD4~+CD25(High)Foxp3~+Treg细胞比例和Foxp3基因表达水平较治疗前明显增高(P＜0.01),其中联用静注丙种球蛋白和激素组的增高水平更为明显(P＜0.01);联用静注丙种球蛋白和激素治疗的AITP患儿血小板恢复正常所需的时间比单用激素组明显缩短(P＜0.05)。
结论CD4~+CD25~(High)Foxp3~+Treg细胞比例下降及Foxp3基因表达降低是AITP的发病机制之一,丙种球蛋白和激素可以通过诱导CD4~+CD25~(High)Foxp3~+Treg的扩增及活化发挥治疗AITP的作用。
第三部分儿童特发性血小板减少性紫癜淋巴毒素基因多态性分析
目的研究中国湖北地区特发性血小板减少性紫癜患儿LTα+252位点基因多态性的分布,探讨LTα不同基因型与ITP发病易感性的可能关系。
方法用PCR—RFLP法检测88例ITP患儿与100例健康儿童LTα+252位点基因的多态性,比较两组患儿不同基因型出现的频率。
结果ITP患儿LTα+252位点G/G、G/A、A/A基因型频率分别为27.27%、50.00%、22.72%,与正常儿童相比无明显统计学差异(P＞0.05)。
结论中国湖北地区儿童LTα+252位点基因多态性与ITP发病无明显相关性。
PartⅠClinic Study on Cell Immune Conditions and Curative Turnover of Idiopathic Thrombocytopenic Purpura with Human Cyto-megalovirus Infection in Children
Objective Exploring the correlation between HCMV infection and the onset, therapeutic effect and prognosis in children with idiopathic thrombocytopenic purpura(ITP), in order to give some reference for more effective treatment of this disease.
Methods Comparing the HCMV infection rate and cell immune conditions between 230 children with ITP and the control group of 200 children with acute upper respiratory infection(AURI) treated in our department between January,2002 to December,2006,by testing the serum HCMV antibodies with ELISA method and detecting the peripheral blood lymohocyte subsets with flow cytometry individually.Further,ITP patients were divided into two groups based on whether they were infected with HCMV or not..The two groups were compared with regard to the cell immune conditions,short-term effectiveness of treatment(two weeks) and long-term results(over six months).
Results 88 out of 230(38.26%) ITP children were found with HCMV infection,and 165 cases(71.74%) with abnormal peripheral blood lymphocyte subgroup.22 out of 200 (11.0%)AURI patients were found with HCMV infection,and 36 cases(18.0%) with abnormal lymphocyte subgroup.There was a significant difference between these two groups(P＜0.01).At the first visit,74(84.09%) were found with abnormal cell immune condition in the HCMV group,and 91(64.08%) in non-infected group;after 6 months, 24(27.27%) were found abnormal in the HCMV group,and 5(3.52%) in non-infected ones. There was a remarkable difference between these two groups(P＜0.01).No significant difference existed in the short-term effectiveness of treatment between the group with HCMV infection and the group without that(P＞0.05).35 cases(39.78%) in the HCMV group had a course over 6 months,whereas 24(16.90%) in non-infected group.The difference is significant(P＜0.01).20 out of 34(58.82%) had a course over 6 months in the regular therapy group,and 15 out of 54(27.78%) did in the antivirus therapy group.The difference is also significant(P＜0.01).
Conclusion Abnormal cell immune conditions induced by HCMV infection is probably one of the important factors that make a prolonged course of ITP in children. Further more,our study showed that anti-HCMV therapy resulted in good recovery of children from ITP with little side effect and that most children tolerated well to the therapy.
PartⅡThe change of CD4+CD25HighFoxp3+Treg cell and the Foxp3 gene expression in childhood acute idiopathic thrombocytopenic purpura before and after treatment
Objective Exploring the CD4~+CD25~(High)Foxp3~+Treg cell function in the mechanism of acute idiopathic thrombocytopenic purpura and the role in therapy with gamma globulin and adrenal corticoid by studying the change of CD4~+CD25~(High)Foxp3~+Treg cell percentage and the Foxp3 gene expression before and after treatment of acute idiopathic thrombocytopenic purpura.
Method The change of CD4~+CD25~(High)Foxp3~+Treg cell percentage was detected by flow cytometry,while the expression of Foxp3 gene was tested by RT-PCR.
Results The CD4~+CD25~(High)Foxp3~+Treg cell percentage and the Foxp3 gene expression in acute idiopathic thrombocytopenic purpura group before treatment were significantly lower than those of the normal control group(P＜0.01),but after treatment with adrenal corticoid alone or plus gamma globulin,the CD4~+CD25~(High)Foxp3~+Treg cell percentage and the Foxp3 gene expression in acute idiopathic thrombocytopenic purpura group rose obviously higher than those of the normal control group(P＜0.01).Compared with group treated with adrenal corticoid alone,the group treated with corticoid plus gamma globulin was remarkly higher in CD4~+CD25~(High)Foxp3~+Treg cell percentage and the expression of Foxp3 gene.Meanwhile,the recovery time of platelet number in group treated with corticoid plus gamma globulin was significantly shorter than that of using corticoid only(P＜0.05).
Conclusion The decreasing of CD4~+CD25~(High)Foxp3~+Treg cell and the Foxp3 gene expression play a role in the mechanism of children acute idiopathic thrombocytopenic purpura.Furthermore,adrenal corticoid and gamma globulin have a therapeutic effect on acute idiopathic thrombocytopenic purpura by inducing the expansion and activation of CD4~+CD25~(High)Foxp3~+Treg cell.
PartⅢAnalysis of lymphotoxin gene polymorphism in children with idiopathic thrombocytopenic purpura
Objective To study on the gene polymorphism of LTα+252 distribution in children with ITP in Hubei,China,and explore the association of genotype frequency of LTαgene with the susceptivity of ITP.
Method Eighty- eight ITP children and one hundred health controls were genotyped by the PCR-RFLP method for gene polymorphism of LTα+252,then compared the genotypes frequency between these two groups.
Result The genotypes frequency of LTα+252G/G、G/A、A/A in ITP children were 27.27%、50.00%、22.72%individually,and there were no statistic difference compared with the control group.
Conclusion No association was detected between the heterozygous genotype of LTα+252 and ITP in children of Hubei,China.
引文
Yetman RJ.Evaluation and management of childhood idiopathic(immune)thrombocytopenia.J Pediatr Health Care,2003,17:261-3.
2 Blanchette V,Freedman J,Garvey B.Management of chronic immune thrombocytopenic purpura in children and adults.Semin Hematol,1998,35:36-51.
3 Imbach P,Kuhne T,Blanchette V.Overview of the State of the Art Expert Meeting of the Intercontinental Childhood ITP Study Group(ICIS).J Pediatr Hematol Oncol,2003,25 Suppl 1:S1-6.
4 France EK,Glanz J,Xu S,et al.Risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children.Pediatrics,2008,121:e687-92.
5 Oldstone MB.Molecular mimicry and immune-mediated diseases.FASEB J,1998,12:1255-65.
6 Klenovsek K,Weisel F,Schneider A,et al.Protection from CMV infection in immunodeficient hosts by adoptive transfer of memory B cells.Blood,2007,110:3472-9.
7 金玲,张永红。儿童130例人巨细胞病毒感染的血液学有关表现[J].中国小儿血液与肿瘤杂志,2006,11(6):302-304.
8 胡亚美,江载芳.诸福堂实用儿科学[M].7版.人民卫生出版社,2004:1800-1803.
9 吴润晖,吴敏媛,马晓莉,等.儿童特发性血小板减少性紫癜患者的免疫状态研究[J].血栓与止血学,2006,12(6):245-249.
10 Grefte JM,van der Gun BT,Schmolke S,et al.The lower matrix protein pp65 is the principal viral antigen present in peripheral blood leukocytes during an active cytomegalovirus infection.J Gen Virol,1992,73(Pt 11):2923-32.
11 Lee AW,Hertel L,Louie RK,et al.Human cytomegalovirus alters localization of MHC class Ⅱ and dendrite morphology in mature Langerhans cells.J Immunol,2006,177:3960-71.
12 Nugent DJ.Immune thrombocytopenic purpura of childhood.Hematology Am Soc Hematol Educ Program,2006:97-103.
13 Roark JH,Bussel JB,Cines DB,et al.Genetic analysis of autoantibodies in idiopathic thrombocytopenic purpura reveals evidence of clonal expansion and somatic mutation.Blood,2002,100:1388-98.
14 窦娟,王清文,袁中明,等。人巨细胞病毒感染抑制原巨核细胞增殖并诱导其凋亡[J].医学信息,2007,20(12):2084-2087.
15 张国栋,闵捷。细胞免疫及体液免疫在ITP发生发展中的作用及其机制探讨[J].山东医药,2007,47(17):35-36.
16 Andersson PO,Stockelberg D,Jacobsson S,et al.A transforming growth factor-betal-mediated bystander immune suppression could be associated with remission of chronic idiopathic thrombocytopenic purpura.Ann Hematol,2000,79:507-13.
17 Semple JW,Bruce S,Freedman J.Suppressed natural killer cell activity in patients with chronic autoimmune thrombocytopenic purpura.Am J Hematol,1991,37:258-62.
18 Sakakura M,Wada H,Tawara I,et al.Reduced Cd4+Cd25+ T cells in patients with idiopathic thrombocytopenic purpura.Thromb Res,2007,120:187-93.
19 朱单丹,方峰,舒赛男,等。巨细胞病毒感染对调节T细胞和Ⅰ型、Ⅱ型辅助性T细胞分化增殖的影响[J].临床儿科杂志,2007,25(7):537-246.
20 Solomou EE,Rezvani K,Mielke S,et al.Deficient CD4+ CD25+ FOXP3+ T regulatory cells in acquired aplastic anemia.Blood,2007,110:1603-6.
1 Arnold DM,Kelton JG.Current options for the treatment of idiopathic thrombocytopenic purpura.Semin Hematol,2007,44:S12-23.
2 Ibanez C,Montoro-Ronsano JB.Intravenous immunoglobulin preparations and autoimmune disorders:mechanisms of action.Curr Pharm Biotechnol,2003,4:239-47.
3 胡亚美,江载芳.诸福堂实用儿科学.人民卫生出版社,2002,第7版:1801-1803.
4 Wolf C,Bruss M,Hanisch B,et al.Molecular basis for the antiproliferative effect of agmatine in tumor cells of colonic,hepatic,and neuronal origin.Mol Pharmacol,2007,71:276-83.
5 Curti A,Pandolfi S,Valzasina B,et al.Modulation of tryptophan catabolism by human leukemic cells results in the conversion of CD25- into CD25+ T regulatory cells.Blood,2007,109:2871-7.
6 Filion MC,Proulx C,Bradley A J,et al.Presence in peripheral blood of healthy individuals of autoreactive T cells to a membrane antigen present on bone marrow-derived cells.Blood,1996,88:2144-50.
7 Cools N,Ponsaerts P,Van Tendeloo VF,et al.Regulatory T cells and human disease.Clin Dev Immunol,2007,2007:89195.
8 Pillai V,Karandikar NJ.Human regulatory T cells:a unique,stable thymic subset or a reversible peripheral state of differentiation?.Immunol Lett,2007,114:9-15.
9 Stasi R,Cooper N,Del Poeta G,et al.Analysis of regulatory T-cell changes in patients with idiopathic thrombocytopenic purpura receiving B cell-depleting therapy with rituximab.Blood,2008,112:1147-50.
10 Sakakura M,Wada H,Tawara I,et al.Reduced Cd4+Cd25+ T cells in patients with idiopathic thrombocytopenic purpura.Thromb Res,2007,120:187-93.
11 Lopes JE,Torgerson TR,Schubert LA,et al.Analysis of FOXP3 reveals multiple domains required for its function as a transcriptional repressor.J Immunol,2006,177:3133-42.
12 Fehr J,Hofmann V,Kappeler U.Transient reversal of thrombocytopenia in idiopathic thrombocytopenic purpura by high-dose intravenous gamma globulin.N Engl J Med,1982,306:1254-8.
13 Imbach P,Barandun S,d'Apuzzo V,et al.High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura in childhood.Lancet,1981,1:1228-31.
14 Diaz Conradi A,Diaz de Heredia C,Tusell Puigbert J,et al.[Chronic and recurrent immune thrombocytopenic purpura].An Pediatr(Barc),2003,59:6-12.
15 Park-Min KH,Serbina NV,Yang W,et al.FcgammaRⅢ-dependent inhibition of interferon-gamma responses mediates suppressive effects of intravenous immune globulin.Immunity,2007,26:67-78.
16 Clynes R.IVIG therapy:interfering with interferon-gamma.Immunity,2007,26:4-6.
17 Bussel JB.Modulation of Fc receptor clearance and antiplatelet antibodies as a consequence of intravenous immune globulin infusion in patients with immune thrombocytopenic purpura.J Allergy Clin Immunol,1989,84:566-77;discussion 577-8.
18 Modiano JF,Amran D,Lack G,et al.Posttranscriptional regulation of T-cell IL-2production by human pooled immunoglobin.Clin Immunol Immunopathol,1997,83:77-85.
19 Andersson J,Skansen-Saphir U,Sparrelid E,et al.Intravenous immune globulin affects cytokine production in T lymphocytes and monocytes/macrophages.Clin Exp Immunol,1996,104 Suppl 1:10-20.
20 卢雪红,于春雷,李一.SLE患者外周血CD4+CD25+调节性T细胞及相关基因Foxp3的变化.中国老年学杂志,2007,1(27):99-101.
21 Yu J,Heck S,Patel V,et al.Defective circulating CD25 regulatory T cells in patients with chronic immune thrombocytopenic purpura.Blood,2008,112:1325-8.
1 Daniel T, Lars K, Eric H, et al. Tumor necrosis factor antagonist mechanisms of action:A comprehensive review. Pharmacology & Therapeutics, 2008,117:244-79.
2 Arend WP, Dayer JM. Cytokines and cytokine inhibitors or antagonists in rheumatoid arthritis. Arthritis Rheum, 1990,33:305-15.
3 Lu LY, Cheng HH, Sung PK, et al. Tumor necrosis factor-beta +252A polymorphism is associated with systemic lupus erythematosus in Taiwan. J Formos Med Assoc,2005,104:563-70.
4 Satoh T, Pandey JP, Okazaki Y, et al. Single nucleotide polymorphisms of the inflammatory cytokine genes in adults with chronic immune thrombocytopenic purpura.Br J Haematol, 2004,124:796-801.
5 Li C, Xia B, Yang Y, et al. TNF gene polymorphisms and Helicobacter Pylori infection in gastric carcinogenesis in Chinese population. Am J Gastroenterol, 2005,100:290-4.
6 Weiser S, Miu J, Ball HJ, et al. Interferon-gamma synergises with tumour necrosis factor and lymphotoxin-alpha to enhance the mRNA and protein expression of adhesion molecules in mouse brain endothelial cells. Cytokine, 2007,37:84-91.
7 Suna S, Sakata Y, Sato H, et al. Up-regulation of cell adhesion molecule genes in human endothelial cells stimulated by lymphotoxin alpha: DNA microarray analysis. J Atheroscler Thromb, 2008,15:160-5.
8 Feldmann M, Steinman L. Design of effective immunotherapy for human autoimmunity. Nature, 2005,435:612-9.
9 Franki AS, Van Beneden K, Dewint P, et al. A unique lymphotoxin {alpha}beta-dependent pathway regulates thymic emigration of V{alpha}14 invariant natural killer T cells. Proc Natl Acad Sci U S A, 2006,103:9160-5.
10 McDonald KG, McDonough JS, Newberry RD. Adaptive immune responses are dispensable for isolated lymphoid follicle formation: antigen-naive, lymphotoxin-sufficient B lymphocytes drive the formation of mature isolated lymphoid follicles. J Immunol, 2005,174:5720-8.
11 Wang H, Feng J, Qi C, et al. An ENU-induced mutation in the lymphotoxin alpha gene impairs organogenesis of lymphoid tissues in C57BL/6 mice. Biochem Biophys Res Commun, 2008,370:461-7.
12 White A, Carragher D, Parnell S, et al. Lymphotoxin a-dependent and -independent signals regulate stromal organizer cell homeostasis during lymph node organogenesis.Blood, 2007,110:1950-9.
13 Chin RK, Zhu M, Christiansen PA, et al. Lymphotoxin pathway-directed, autoimmune regulator-independent central tolerance to arthritogenic collagen. J Immunol,2006,177:290-7.
14 Tumanov AV, Christiansen PA, Fu YX. The role of lymphotoxin receptor signaling in diseases. Curr Mol Med, 2007,7:567-78.
15 Eissner G, Kolch W, Scheurich P. Ligands working as receptors: reverse signaling by members of the TNF superfamily enhance the plasticity of the immune system.Cytokine Growth Factor Rev, 2004,15:353-66.
16 Hashimoto T, Schlessinger D, Cui CY. Troy binding to lymphotoxin-alpha activates NF kappa B mediated transcription. Cell Cycle, 2008,7:106-11.
17 Iizuka K, Chaplin DD, Wang Y, et al. Requirement for membrane lymphotoxin in natural killer cell development. Proc Natl Acad Sci U S A, 1999,96:6336-40.
18 Ito D, Back TC, Shakhov AN, et al. Mice with a targeted mutation in lymphotoxin-alpha exhibit enhanced tumor growth and metastasis: impaired NK cell development and recruitment. J Immunol, 1999,163:2809-15.
19 Messer G, Spengler U, Jung MC, et al. Polymorphic structure of the tumor necrosis factor (TNF) locus: an Ncol polymorphism in the first intron of the human TNF-beta gene correlates with a variant amino acid in position 26 and a reduced level of TNF-beta production. J Exp Med, 1991,173:209-19.
20 Stuber F, Petersen M, Bokelmann F, et al. A genomic polymorphism within the tumor necrosis factor locus influences plasma tumor necrosis factor-alpha concentrations and outcome of patients with severe sepsis. Crit Care Med, 1996,24:381-4.
21 Bettinotti MP, Hartung K, Deicher H, et al. Polymorphism of the tumor necrosis factor beta gene in systemic lupus erythematosus: TNFB-MHC haplotypes. Immunogenetics,1993,37:449-54.
22 Badenhoop K, Schwarz G, Schleusener H, et al. Tumor necrosis factor beta gene polymorphisms in Graves' disease. J Clin Endocrinol Metab, 1992,74:287-91.
23 Pandey JP, Takeuchi F. TNF-alpha and TNF-beta gene polymorphisms in systemic sclerosis. Hum Immunol, 1999,60:1128-30.
24 Mak JC, Ko FW, Chu CM, et al. Polymorphisms in the IL-4, IL-4 receptor alpha chain,TNF-alpha, and lymphotoxin-alpha genes and risk of asthma in Hong Kong Chinese adults. Int Arch Allergy Immunol, 2007,144:114-22.
25 McMinn JR Jr, Cohen S, Moore J, et al. Complete recovery from refractory immune thrombocytopenic purpura in three patients treated with etanercept. Am J Hematol,2003,73:135-40.
26 Chou CT. The clinical application of etanercept in Chinese patients with rheumatic diseases. Mod Rheumatol, 2006,16:206-13.
27 Suzuki T, Matsushima M, Shirakura K, et al. Association of inflammatory cytokine gene polymorphisms with platelet recovery in idiopathic thrombocytopenic purpura patients after the eradication of Helicobacter pylori. Digestion, 2008,77:73-8.
1 Psaila B, Bussel JB. Refractory immune thrombocytopenic purpura: current strategies for investigation and management. Br J Haematol, 2008.
2 Neunert CE, Bright BC, Buchanan GR. Severe chronic refractory immune thrombocytopenic purpura during childhood: A survey of physician management.Pediatr Blood Cancer, 2008.
3 Kalpatthi R, Bussel JB. Diagnosis, pathophysiology and management of children with refractory immune thrombocytopenic purpura. Curr Opin Pediatr, 2008,20:8-16.
4 Stevens W, Koene H, Zwaginga JJ, et al. Chronic idiopathic thrombocytopenic purpura: present strategy, guidelines and new insights. Neth J Med, 2006,64:356-63.
5 Psaila B, Bussel JB. Refractory immune thrombocytopenic purpura: current strategies for investigation and management. Br J Haematol, 2008,143:16-26.
6 Fujisawa K, O'Toole TE, Tani P, et al. Autoantibodies to the presumptive cytoplasmic domain of platelet glycoprotein IIIa in patients with chronic immune thrombocytopenic purpura. Blood, 1991,77:2207-13.
7 Sukati H, Watson HG, Urbaniak SJ, et al. Mapping helper T-cell epitopes on platelet membrane glycoprotein IIIa in chronic autoimmune thrombocytopenic purpura. Blood,2007,109:4528-38.
8 Kuwana M, Kaburaki J, Ikeda Y. Autoreactive T cells to platelet GPIIb-IIIa in immune thrombocytopenic purpura. Role in production of anti-platelet autoantibody. J Clin Invest, 1998,102:1393-402.
9 Oldstone MB. Molecular mimicry and immune-mediated diseases. FASEB J,1998,12:1255-65.
10 Wright JF, Blanchette VS, Wang H, et al. Characterization of platelet-reactive antibodies in children with varicella-associated acute immune thrombocytopenic purpura (ITP). Br J Haematol, 1996,95:145-52.
11 Gruel Y, Boizard B, Daffos F, et al. Determination of platelet antigens and glycoproteins in the human fetus. Blood, 1986,68:488-92.
12 Filion MC, Proulx C, Bradley AJ, et al. Presence in peripheral blood of healthy individuals of autoreactive T cells to a membrane antigen present on bone marrow-derived cells. Blood, 1996,88:2144-50.
13 Lo D, Freedman J, Hesse S, et al. Peripheral tolerance in transgenic mice: tolerance to class II MHC and non-MHC transgene antigens. Immunol Rev, 1991,122:87-102.
14 Dubois B, Chapat L, Goubier A, et al. CD4+CD25+ T cells as key regulators of immune responses. Eur J Dermatol, 2003,13:111-6.
15 Takai T. Roles of Fc receptors in autoimmunity. Nat Rev Immunol, 2002,2:580-92.
16 Van Kooten C, Banchereau J. CD40-CD40 ligand: a multifunctional receptor-ligand pair. Adv Immunol, 1996,61:1-77.
17 Biancone L, Cantaluppi V, Camussi G. CD40-CD154 interaction in experimental and human disease (review). Int J Mol Med, 1999,3:343-53.
18 Semple JW, Freedman J. Increased antiplatelet T helper lymphocyte reactivity in patients with autoimmune thrombocytopenia. Blood, 1991,78:2619-25.
19 Peng J, Liu C, Liu D, et al. Effects of B7-blocking agent and/or CsA on induction of platelet-specific T-cell anergy in chronic autoimmune thrombocytopenic purpura.Blood, 2003,101:2721-6.
20 Bruhns P, Samuelsson A, Pollard JW, et al. Colony-stimulating factor-1-dependent macrophages are responsible for IVIG protection in antibody-induced autoimmune disease. Immunity, 2003,18:573-81.
21 Binstadt BA, Geha RS, Bonilla FA. IgG Fc receptor polymorphisms in human disease: implications for intravenous immunoglobulin therapy. J Allergy Clin Immunol,2003,111:697-703.
22 Ogawara H, Handa H, Morita K, et al. High Thl/Th2 ratio in patients with chronic idiopathic thrombocytopenic purpura. Eur J Haematol, 2003,71:283-8.
23 Semple JW, Milev Y, Cosgrave D, et al. Differences in serum cytokine levels in acute and chronic autoimmune thrombocytopenic purpura: relationship to platelet phenotype and antiplatelet T-cell reactivity. Blood, 1996,87:4245-54.
24 Panitsas FP, Mouzaki A. Effect of splenectomy on type-1/type-2 cytokine gene expression in a patient with adult idiopathic thrombocytopenic purpura (ITP). BMC Blood Disord, 2004,4:4.
25 Agarwal SK, Marshall GD Jr. Dexamethasone promotes type 2 cytokine production primarily through inhibition of type 1 cytokines. J Interferon Cytokine Res, 2001,21:147-55.
26 Mouzaki A, Theodoropoulou M, Gianakopoulos I, et al. Expression patterns of Th1 and Th2 cytokine genes in childhood idiopathic thrombocytopenic purpura (ITP) at presentation and their modulation by intravenous immunoglobulin G (IVIg) treatment:their role in prognosis. Blood, 2002,100:1774-9.
27 Sarvetnick N, Shizuru J, Liggitt D, et al. Loss of pancreatic islet tolerance induced by beta-cell expression of interferon-gamma. Nature, 1990,346:844-7.
28 Cross D, Cambier JC. Transforming growth factor beta 1 has differential effects on B cell proliferation and activation antigen expression. J Immunol, 1990,144:432-9.
29 Defrance T, Vanbervliet B, Briere F, et al. Interleukin 10 and transforming growth factor beta cooperate to induce anti-CD40-activated naive human B cells to secrete immunoglobulin A. J Exp Med, 1992,175:671-82.
30 Sakakura M, Wada H, Tawara I, et al. Reduced Cd4+Cd25+ T cells in patients with idiopathic thrombocytopenic purpura. Thromb Res, 2007,120:187-93.
31 Liu B, Zhao H, Poon MC, et al. Abnormality of CD4(+)CD25(+) regulatory T cells in idiopathic thrombocytopenic purpura. Eur J Haematol, 2007,78:139-43.
32 Fahim NM, Monir E. Functional role of CD4+CD25+ regulatory T cells and transforming growth factor-betal in childhood immune thrombocytopenic purpura.Egypt J Immunol, 2006,13:173-87.
33 Stasi R, Cooper N, Del Poeta G, et al. Analysis of regulatory T-cell changes in patients with idiopathic thrombocytopenic purpura receiving B cell-depleting therapy with rituximab. Blood, 2008,112:1147-50.
34 Yu J, Heck S, Patel V, et al. Defective circulating CD25 regulatory T cells in patients with chronic immune thrombocytopenic purpura. Blood, 2008,112:1325-8.
35 Olsson B, Ridell B, Carlsson L, et al. Recruitment of T cells into bone marrow of ITP patients possibly due to elevated expression of VLA-4 and CX3CR1. Blood,2008,112:1078-84.
36 Warner MN, Moore JC, Warkentin TE, et al. A prospective study of protein-specific assays used to investigate idiopathic thrombocytopenic purpura. Br J Haematol,1999,104:442-7.
37 Brighton TA, Evans S, Castaldi PA, et al. Prospective evaluation of the clinical usefulness of an antigen-specific assay (MAIPA) in idiopathic thrombocytopenic purpura and other immune thrombocytopenias. Blood, 1996,88:194-201.
38 Stockelberg D, Hou M, Jacobsson S, et al. Detection of platelet antibodies in chronic idiopathic thrombocytopenic purpura (ITP). A comparative study using flow cytometry, a whole platelet ELISA, and an antigen capture ELISA. Eur J Haematol, 1996,56:72-7.
39 Olsson B, Andersson PO, Jernas M, et al. T-cell-mediated cytotoxicity toward platelets in chronic idiopathic thrombocytopenic purpura. Nat Med, 2003,9:1123-4.
40 Chang M, Nakagawa PA, Williams SA, et al. Immune thrombocytopenic purpura (ITP) plasma and purified ITP monoclonal autoantibodies inhibit megakaryocytopoiesis in vitro. Blood, 2003,102:887-95.
41 Takahashi R, Sekine N, Nakatake T. Influence of monoclonal antiplatelet glycoprotein antibodies on in vitro human megakaryocyte colony formation and proplatelet formation. Blood, 1999,93:1951-8.
42 Bussel J. Treatment of immune thrombocytopenic purpura in adults. Semin Hematol,2006,43:S3-10; discussion S18-9.
43 Ucar C, Oren H, Irken G, et al. Investigation of megakaryocyte apoptosis in children with acute and chronic idiopathic thrombocytopenic purpura. Eur J Haematol,2003,70:347-52.
44 Houwerzijl EJ, Blom NR, van der Want JJ, et al. Ultrastructural study shows morphologic features of apoptosis and para-apoptosis in megakaryocytes from patients with idiopathic thrombocytopenic purpura. Blood, 2004,103:500-6.
45 Houwerzijl EJ, Blom NR, van der Want JJ, et al. Megakaryocytic dysfunction in myelodysplastic syndromes and idiopathic thrombocytopenic purpura is in part due to different forms of cell death. Leukemia, 2006,20:1937-42.
46 Blanchette V, Bolton-Maggs P. Childhood immune thrombocytopenic purpura: diagnosis and management. Pediatr Clin North Am, 2008,55:393-420, ix.
47 Anoop P. Decision to perform bone marrow aspiration in immune thrombocytopenic purpura must be based on evidence. Pediatr Hematol Oncol, 2008,25:91-2.
48 Geddis AE, Balduini CL. Diagnosis of immune thrombocytopenic purpura in children.Curr Opin Hematol, 2007,14:520-5.
49 Beardsley DS. ITP in the 21st century. Hematology Am Soc Hematol Educ Program,2006:402-7.
50 Sevier N, Houston M. Chronic refractory ITP in children: beyond splenectomy. J Pediatr Oncol Nurs, 2005,22:145-51.
51 Imbach P. Refractory idiopathic immune thrombocytopenic purpura in children: current and future treatment options. Paediatr Drugs, 2003,5:795-801.
52 Rodeghiero F. First-line therapies for immune thrombocytopenic purpura: re-evaluating the need to treat. Eur J Haematol Suppl, 2008:19-26.
53 Rodeghiero F, Ruggeri M. Is splenectomy still the gold standard for the treatment of chronic ITP?. Am J Hematol, 2008,83:91.
54 Cines DB, Bussel JB. How I treat idiopathic thrombocytopenic purpura (ITP). Blood,2005,106:2244-51.
55 Tarantino M. Recent advances in the treatment of childhood immune thrombocytopenic purpura. Semin Hematol, 2006,43:S11-7; discussion S18-9.
56 Neunert CE, Bright BC, Buchanan GR. Severe chronic refractory immune thrombocytopenic purpura during childhood: a survey of physician management.Pediatr Blood Cancer, 2008,51:513-6.
57 Kumar M, Vik TA, Johnson CS, et al. Treatment, outcome, and cost of care in children with idiopathic thrombocytopenic purpura. Am J Hematol, 2005,78:181-7.
58 Mazzucconi MG, Fazi P, Bernasconi S, et al. Therapy with high-dose dexamethasone (HD-DXM) in previously untreated patients affected by idiopathic thrombocytopenic purpura: a GIMEMA experience. Blood, 2007,109:1401-7.
59 Chen JS, Wu JM, Chen YJ, et al. Pulsed high-dose dexamethasone therapy in children with chronic idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol,1997,19:526-9.
60 Ancona KG, Parker RI, Atlas MP, et al. Randomized trial of high-dose methylprednisolone versus intravenous immunoglobulin for the treatment of acute idiopathic thrombocytopenic purpura in children. J Pediatr Hematol Oncol,2002,24:540-4.
61 Lusher JM, Warrier I. Use of intravenous gamma globulin in children and adolescents with idiopathic thrombocytopenic purpura and other immune thrombocytopenias. Am J Med, 1987,83:10-6.
62 Peterlana D, Puccetti A, Simeoni S, et al. Efficacy of intravenous immunoglobulin in chronic idiopathic pericarditis: report of four cases. Clin Rheumatol, 2005,24:18-21.
63 Bussel JB. Fc receptor blockade and immune thrombocytopenic purpura. Semin Hematol, 2000,37:261-6.
64 Jin F, Balthasar JP. Mechanisms of intravenous immunoglobulin action in immune thrombocytopenic purpura. Hum Immunol, 2005,66:403-10.
65 Park-Min KH, Serbina NV, Yang W, et al. FcgammaRIII-dependent inhibition of interferon-gamma responses mediates suppressive effects of intravenous immune globulin. Immunity, 2007,26:67-78.
66 Ware RE, Zimmerman SA. Anti-D: mechanisms of action. Semin Hematol, 1998,35:14-22.
67 Smith N. Intravenous anti-D immunoglobulin in the management of immune thrombocytopenic purpura. Curr Opin Hematol, 1996,3:498-503.
68 Aledort LM, Salama A, Kovaleva L, et al. Efficacy and safety of intravenous anti-D immunoglobulin (Rhophylac) in chronic immune thrombocytopenic purpura.Hematology, 2007,12:289-95.
69 Kjaersgaard M, Hasle H. A review of anti-D treatment of childhood idiopathic thrombocytopenic purpura. Pediatr Blood Cancer, 2006,47:717-20.
70 Ramadan KM, El-Agnaf M. Efficacy and response to intravenous anti-D immunoglobulin in chronic idiopathic thrombocytopenic purpura. Clin Lab Haematol,2005,27:267-9.
71 Kojouri K, George JN. Recent advances in the treatment of chronic refractory immune thrombocytopenic purpura. Int J Hematol, 2005,81:119-25.
72 Boruchov DM, Gururangan S, Driscoll MC, et al. Multiagent induction and maintenance therapy for patients with refractory immune thrombocytopenic purpura (ITP). Blood, 2007,110:3526-31.
73 Williams JA, Boxer LA. Combination therapy for refractory idiopathic thrombocytopenic purpura in adolescents. J Pediatr Hematol Oncol, 2003,25:232-5.
74 Moskowitz IP, Gaynon PS, Shahidi NT, et al. Low-dose cyclosporin A therapy in children with refractory immune thrombocytopenic purpura. J Pediatr Hematol Oncol,1999,21:77-9.
75 Sikorska A, Slomkowski M, Marlanka K, et al. The use of vinca alkaloids in adult patients with refractory chronic idiopathic thrombocytopenia. Clin Lab Haematol,2004,26:407-11.
76 Szczepanik AB, Sikorska A, Slomkowski M, et al. The use of vinca alkaloids in preparation for splenectomy of corticosteroid refractory chronic immune thrombocytopenic purpura patients. Int J Lab Hematol, 2007,29:347-51.
77 Verlin M, Laros RK Jr, Penner JA. Treatment of refractory thrombocytopenic purpura with cyclophosphamine. Am J Hematol, 1976,1:97-104.
78 Pizzuto J, Ambriz R. Therapeutic experience on 934 adults with idiopathic thrombocytopenic purpura: Multicentric Trial of the Cooperative Latin American group on Hemostasis and Thrombosis. Blood, 1984,64:1179-83.
79 Quiquandon I, Fenaux P, Caulier MT, et al. Re-evaluation of the role of azathioprine in the treatment of adult chronic idiopathic thrombocytopenic purpura: a report on 53 cases. Br J Haematol, 1990,74:223-8.
80 Fan H, Zhu HL, Li SX, et al. [Therapy of 17 cases of idiopathic thrombocytopenia purpura by amifostine]. Zhongguo Shi Yan Xue Ye Xue Za Zhi, 2008,16:192-6.
81 Fan H, Zhu HL, Yao SQ, et al. [Early effect of amifostine in treating aged patients with idiopathic thrombocytopenia purpura]. Zhongguo Shi Yan Xue Ye Xue Za Zhi,2006,14:301-3.
82 Ahn YS, Harrington WJ, Simon SR, et al. Danazol for the treatment of idiopathic thrombocytopenic purpura. N Engl J Med, 1983,308:1396-9.
83 Maloisel F, Andres E, Zimmer J, et al. Danazol therapy in patients with chronic idiopathic thrombocytopenic purpura: long-term results. Am J Med, 2004,116:590-4.
84 Schiavotto C, Castaman G, Rodeghiero F. Treatment of idiopathic thrombocytopenic purpura (ITP) in patients with refractoriness to or with contraindication for corticosteroids and/or splenectomy with immunosuppressive therapy and danazol.Haematologica, 1993,78:29-34.
85 Donato H, Kohan R, Picon A, et al. Alpha-interferon therapy induces improvement of platelet counts in children with chronic idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol, 2001,23:598-603.
86 Dikici B, Bosnak M, Kara IH, et al. Interferon-alpha therapy in idiopathic thrombocytopenic purpura. Pediatr Int, 2001,43:577-80.
87 Provan D, Moss AJ, Newland AC, et al. Efficacy of mycophenolate mofetil as single-agent therapy for refractory immune thrombocytopenic purpura. Am J Hematol,2006,81:19-25.
88 Pescovitz MD. Rituximab, an anti-cd20 monoclonal antibody: history and mechanism of action. Am J Transplant, 2006,6:859-66.
89 Braendstrup P, Bjerrum OW, Nielsen OJ, et al. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adult refractory idiopathic thrombocytopenic purpura. Am J Hematol, 2005,78:275-80.
90 Kuwana M, Nomura S, Fujimura K, et al. Effect of a single injection of humanized anti-CD154 monoclonal antibody on the platelet-specific autoimmune response in patients with immune thrombocytopenic purpura. Blood, 2004,103:1229-36.
91 Kuwana M, Kawakami Y, Ikeda Y. Suppression of autoreactive T-cell response to glycoprotein IIb/IIIa by blockade of CD40/CD154 interaction: implications for treatment of immune thrombocytopenic purpura. Blood, 2003,101:621-3.
92 Stasi R, Evangelista ML, Amadori S. Novel thrombopoietic agents: a review of their use in idiopathic thrombocytopenic purpura. Drugs, 2008,68:901-12.
93 Kuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet,2008,371:395-403.
94 Dolan JP, Sheppard BC, DeLoughery TG. Splenectomy for immune thrombocytopenic purpura: surgery for the 21st century. Am J Hematol, 2008,83:93-6.
95 Choi YU, Dominguez EP, Sherman V, et al. Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura. JSLS, 2008,12:314-7.
96 Shojaiefard A, Mousavi SA, Faghihi SH, et al. Prediction of response to splenectomy in patients with idiopathic thrombocytopenic purpura. World J Surg, 2008,32:488-93.
97 Kumar S, Diehn FE, Gertz MA, et al. Splenectomy for immune thrombocytopenic purpura: long-term results and treatment of postsplenectomy relapses. Ann Hematol,2002,81:312-9.
98 Veneri D, Franchini M, Gottardi M, et al. Efficacy of Helicobacter pylori eradication in raising platelet count in adult patients with idiopathic thrombocytopenic purpura.Haematologica, 2002,87:1177-9.
99 Rostami N, Keshtkar-Jahromi M, Rahnavardi M, et al. Effect of eradication of Helicobacter pylori on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura: a controlled trial. Am J Hematol, 2008,83:376-81.
100 Xiao Y, Lin W, Liu Q, et al. [A clinical study on human cytomegalovirus infection in colony forming unit-megakaryocyte in patients with idiopathic thrombocytopenic purpura]. Zhonghua Er Ke Za Zhi, 2006,44:346-9.
101 Yu ZS, Tang LF, Zou CC, et al. Cytomegalovirus-associated idiopathic thrombocytopenic purpura in Chinese children. Scand J Infect Dis, 2008:1-6.
