A 65-year-old male was admitted to our hospital because of ecchymosis on both lower extremities. Three years before admission, he was diagnosed with ITP by laboratory tests, including antibodies against platelet glycoprotein (GP) IIb/IIIa and GP IV, and bone marrow aspiration. He had been treated successfully with corticosteroids. History included nontuberculosis mycobacterial infection. Previous treatment included prednisolone (PSL; 5 mg/day), clarithromycin, rifampicin, and ethambutol hydrochloride. Two weeks before admission, routine laboratory examination showed normal platelet counts (PC; 185 x 109/l).
On admission, laboratory findings showed a PC of 3.0 x 109/l. Biochemical parameters and coagulation values were within the normal limit. Antibodies against Helicobacter pylori, hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) were negative. We diagnosed him with acute exacerbation of chronic ITP. The clinical course is shown in Supplementary Figure 1.
He was treated immediately with high-dose IVIG, PSL (40 mg/day, p.o.), and romiplostim (1 microg/kg). During the next four days, he developed respiratory failure; PaO2/FiO2 ratio was approximately 250. On the fourth day of hospitalization, computed tomography (CT) revealed ground-glass opacities (GGOs) with marginal infiltration in both lung fields, on the basis of which a diagnosis of alveolar hemorrhage was made. His dyspnea worsened gradually, and noninvasive positive pressure ventilation (NPPV) was initiated.
On the 11th day of hospitalization, a higher dose of romiplostim (10 microg/kg) was initiated together with pulsed doses of methyl-PSL (1000 mg/day for 3 days) and a second cycle of IVIG. His PC recovered by the 21st day of hospitalization, and he was discharged without any complications. The patient's PC has remained normal whilst being treated with 12.5 mg of PSL daily for 12 months, without recurrence of alveolar hemorrhage.