UNDERLYING IMMUNE THROMBOCYTOPENIA IN REFRACTORY BIPOLAR DISORDER: A CASE REPORT

Abstract Background Immune thrombocytopenia (ITP) is an acquired condition with various etiologies characterized by a reduction in platelet count which may cause comorbidities and affect the presentation of other diseases. Aims & Objectives We present a case involving a patient with bipolar affective disorder who exhibited symptoms of psychotic mania with delirious features. Despite prior resistance to antipsychotic treatment, a dramatic improvement was observed after underlying ITP alongside a flare-up of hepatitis B virus (HBV) were discovered and treated. Method Case Presentation The 46-year-old woman has been diagnosed with bipolar affective disorder for 10 years. Over the past two years, she presented on and off manic and psychotic symptoms characterized by grandiose delusions and disorganized behaviors, hyperactivity, marked disrupted the role function and became homeless, finally admitted to our acute ward for disruptive behaviors in the society. The disorganized behaviors with perplexity, disorientation, difficulties in self-care had been worsened after admission, despite an initial trial of paliperidone 9mg per day monotherapy, and subsequent attempts with a combination of olanzapine 20mg and chlorpromazine 100mg per day also proved ineffective. Brain computed tomography scan showed no apparent intracranial hemorrhage. Laboratory tests indicated a worsening of thrombocytopenia (32 x 10^3/uL), positive rheumatoid factor (RF), an elevated erythrocyte sedimentation rate (ESR) of 48 mm/hr, a D-dimer level of 655.21 ng/mL, elevated levels of aspartate transaminase (AST) at 103 U/L, and alanine transaminase (ALT) at 100 U/L. Additionally, the patient tested positive for hepatitis B surface antigen (HBsAg), and her serum hepatitis B virus deoxyribonucleic acid (HBV DNA) level was measured at 92,900,000 IU/mL. Abdominal sonography revealed mild fatty liver. Following the discontinuation of antipsychotics and the prescription of prednisolone at a dosage of 10mg per-day and Entecavir at 0.5 mg per-day, both the platelet count and liver function showed significant improvement within 10 days. This was followed by a remarkable improvement not only in symptoms of delirium but also in symptoms of mania, ultimately leading to remission with CGI-I scores of 2. Discussion & Conclusion ITP is a condition characterized with chronic, waxing and waning nature. Its mechanisms included the presence of autoantibodies targeting platelet antigens, inhibition of megakaryocytopoiesis, and T-cell-mediated destruction of platelets. Approximately 20% of cases may have a secondary etiology, which includes underlying autoimmune diseases, lymphoproliferative disorders, or chronic viral infections. Both the uncontrolled ITP and the underlying causes could affect mental status and result in a chronic and difficult-to-control clinical course. Possible mechanisms may include dysregulated immune system responses, elevated levels of serum pro-inflammatory cytokines, increased blood-brain barrier permeability during systemic infection, or occult cerebral microbleeds associated with thrombocytopenia. Conducting a thorough survey for physical comorbidities in patients with refractory mental illness is of paramount importance. References 1.Cines, D.B., Liebman, H. and Stasi, R. (2009). ‘Pathobiology of Secondary Immune Thrombocytopenia’, Seminars in Hematology, 46, pp.S2– S14. doi:https://doi.org/10.1053/j.seminhematol.2008.12.005. 2.Cooper, N., Morrison, M.A., Vladescu, C., Hart, A.C.J., Paul, D., Malik, A., Young, T., Luqmani, A., Atta, M., Sharp, D.J., Bussel, J.B. and Waldman, A.D. (2020). ‘Identification of occult cerebral microbleeds in adults with immune thrombocytopenia’, Blood, 136(25), pp.2875–2880. doi:https://doi.org/10.1182/blood.2020004858. 3.Jeppesen, R. and Benros, M.E. (2019). ‘Autoimmune Diseases and Psychotic Disorders’, Frontiers in Psychiatry, 10. doi:https://doi.org/10.3389/fpsyt.2019.00131. 4.Lambert, M.P. and Gernsheimer, T.B. (2017). ‘Clinical updates in adult immune thrombocytopenia’, Blood, 129(21), pp.2829–2835. doi:https://doi.org/10.1182/blood-2017-03-754119.