Recurrent Immune Thrombocytopenia After Liver Transplantation in a Pediatric Patient: Successful Bridging Treatment With Eltrombopag Before Partial Splenic Embolization and Review of the Literature.

Although thrombocytopenia is a frequent complication that develops after liver transplantation, immune thrombocytopenia rarely occurs post-transplant. We present an 8-year-old boy who experienced 2 immune thrombocytopenia episodes that occurred 72 and 93 months after liver transplant while the patient was on tacrolimus therapy. The patient, who had primary diagnosis being deoxyguanosine kinase deficiency, received a liver transplant from his father at 1 year of age. Parents were first-degree relatives. In both episodes, the patient was admitted because of diffuse petechial lesions that developed 7 to 14 days after upper respiratory tract infection. Laboratory findings were unremarkable except for low platelet count (13 × 109/L and 6 × 109/L) and increased immature megakaryocytes in the bone marrow. The first episode responded to a mega-level dose of methylprednisolone; platelet count remained stable at >150 × 109/L until immune thrombocytopenia recurred 21 months later. The second episode was resistant to standard treatment modalities, including steroid, intravenous immunoglobulin G, and rituximab administration but responded to eltrombopag (starting at 25 mg/day and gradually increased to 75 mg/day) as a bridging regimen for partial splenic embolization and as maintenance therapy for 45 days. Platelet count has remained normal and stable over 3 years. In our literature review, we found 9 children who developed immune thrombocytopenia after liver transplant. In our patient, with response to eltrombopag as a bridging regimen for partial splenic embolization and maintenance therapy and primary liver pathology showing deoxyguanosine kinase deficiency, the posttransplant period before diagnosis of immune thrombocytopenia was longer than periods reported in the literature. These factors make our case unique. Our case highlights the need for clinicians to be aware of posttransplant immune thrombocytopenia, which can develop despite ongoing immunosuppressive therapy, and to differentiate this entity from other causes of thrombocytopenia.