Hematologic manifestations of
Abstract
Helicobacter pylori infection is the most common infection of the human species, with developing countries displaying a marked disadvantage in contrast to developing countries. While H. pylori infection is asymptomatic in most infected individuals, it is intimately related to malignant diseases of the stomach, such as gastric cancer and gastric MALT lymphoma, as well as benign diseases, for example chronic gastritis and duodenal and gastric peptic ulcers. Since the discovery that gastric mucosa could be colonized by bacteria, evidence of greater than 50 extragastric manifestations has been reported, linking H. pylori infection and the development of diseases associated with cardiology, dermatology, endocrinology, obstetrics and gynecology, hematology, pneumology, neurology, odontology, ophthalmology, otorhinolaryngology, and pediatrics. This chapter presents the extragastric manifestations of H. pylori infection expressed through hematologic diseases; particularly those included in the international consensus, and discusses guidelines for the management of H. pylori infection, such as iron deficiency, vitamin B12 (cobalamin) deficiency, and immune thrombocytopenia. Other manifestations reviewed include immune neutropenia, antiphospholipid syndrome, and plasma cell dyscrasias, such us monoclonal gammopathy of undetermined significance, multiple myeloma, and Henoch–Schönlein purpura.
Keywords
- Helicobacter pylori
- iron deficiency
- immune thrombocytopenia
- mucosa-associated lymphoid tissue lymphoma
- vitamin B12 deficiency
1. Introduction
From a practical standpoint, hematological associations with
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Iron deficiency Vitamin B12 deficiency Immune thrombocytopenia Gastric MALT lymphoma |
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Autoimmune neutropenia Antiphospholipid syndrome Plasma cell dyscrasias Henoch–Schönlein purpura Other manifestations: acute leukemia, myelodysplastic syndrome, thrombocytosis |
2. Hematological diseases recognized as related to H. pylori
Until September 2015, the scientific community has recognized three hematologic diseases as extragastric manifestations of
2.1. Iron deficiency
Iron deficiency, with or without anemia (
It is important to note that iron deficiency is a chronic process: an iron imbalance can take several years to become established and manifest clinically or through hemogram (blood cell count) parameters, such as morphological alterations of erythrocytes or anemia, according to the WHO criteria [32]. Three stages of iron deficiency are clearly established: prelatent (Stage 1), when serum ferritin is between 12 µg/L and 30 µg/L; latent (Stage 2), when serum ferritin is below 12 µg/L; and iron deficiency anemia (Stage 3), when anemia is observed in addition to diminished or depleted iron storage levels determined by serum ferritin [35].
2.1.1. H. pylori and iron deficiency
In 1991, in Belgium, Blecker et al. described the first association between iron deficiency and
After these first reports, where iron deficiency disappeared after the eradication of
2.1.2. Pathophysiology of iron deficiency by H. pylori
The pathophysiological mechanisms through which
In the past decade,
Other possible causes of iron imbalance in patients infected with
Beyond the aforementioned evidence, certain highly virulent strains of
2.1.3. Management of iron deficiency in the post-Helicobacter era
Regarding to the management of iron deficiency in the post-
Before initiating treatment for a patient with iron deficiency, an assessment of the prevalence of
After 6–8 weeks of treatment, the infection eradication must be confirmed using a non-invasive test, ideally with 13C-urea breath test [27]. If eradication is not achieved, it is mandatory to establish a new therapy scheme until eradication is achieved. Once
Figure 1 shows a diagnostic and management algorithm of iron deficiency in the post-
2.2. Vitamin B12 deficiency
Vitamin B12, also known as cobalamin, is a coenzyme necessary for the metabolism of amino acids, such as methionine, threonine, and valine, and for DNA synthesis through the conversion of methyl-tetrahydrofolate to tetrahydrofolate [99]. Vitamin B12 is synthesized in mammals, but for humans, their provision depends exclusively of diet intake of animal products [99].
Again, as with iron deficiency, it should be noted that vitamin B12 deficiency is a chronic process, with very slow establishment. It may manifest clinically through neuropsychiatric symptoms or through hemogram parameters, such as morphological alterations of erythrocytes or anemia, according to the WHO criteria [32]. Four stages of vitamin B12 deficiency are clearly established: Stage I, reduction of vitamin B12 levels in blood; Stage II, low amount of vitamin B12 cellular levels and metabolic disorders; Stage III, increase in homocysteine and methylmalonic acid levels and decrease in DNA synthesis with onset of neuropsychiatric symptoms; and Stage IV, macrocytic anemia [100].
Vitamin B12 deficiency is defined in terms of the serum values of vitamin B12 and two components of its metabolic pathway, homocysteine and methylmalonic acid [101]. The diagnosis of vitamin B12 deficiency is established in accordance with the following criteria: (1) serum vitamin B12 < 150 pmol/L (< 200 pg/mL) with clinical manifestations and/or hematological alterations related to vitamin B12 deficiency; (2) serum vitamin B12 < 150 pmol/L, measured on two separate occasions; (3) serum vitamin B12 < 150 pmol/L and serum homocysteine > 13 mmol/L or urinary methylmalonic acid > 0.4 mmol/L (in the absence of renal failure, folic acid deficiency, and vitamin B6 deficiency); and (4) levels of serum holotranscobalamin < 35 pmol/L [102].
The prevalence of vitamin B12 deficiency is highly variable and represents a serious public health problem, depending on the populations analyzed. Epidemiologic studies show that, in the general population of industrialized countries, vitamin B12 deficiency has a prevalence of approximately 20%, with a range between 5% and 60%, depending on the definition of vitamin B12 deficiency that is utilized [101, 102]. The prevalence of vitamin B12 deficiency expressed as pernicious anemia is higher in Latin American countries than in the rest of the world; furthermore, in Latin America, the disease occurs in younger persons [103], while it is associated with advanced age in remaining countries [104].
In addition to its close association to the etiology of pernicious anemia [105] and subacute combined degeneration [106], vitamin B12 deficiency is related, through homocysteine, with dissimilar diseases such as Alzheimer’s disease [107, 108], dementia [109, 110], depression [111], stroke [112, 113], pulmonary embolism [114, 115], acute myocardial infarction, and coronary heart disease [116].
2.2.1. H. pylori and vitamin B12 deficiency
The possibility that pernicious anemia, rather than vitamin B12 deficiency, was associated with
It is currently known that when vitamin B12 deficiency becomes clinically relevant, the bacteria are no longer at the site of the lesion due to changes in the gastric mucosa that result in a hostile environmental niche. In cases of vitamin B12 deficiency and pernicious anemia,
Infection with
The intimately association of pernicious anemia with the probability to develop stomach cancer was widely recognized by scientific community many years before the relationship between
2.2.2. Pathophysiology of vitamin B12 deficiency
The pathophysiological mechanism by which
Vitamin B12 deficiency manifests as antibodies against intrinsic factor and the parietal cells in the stomach, achlorhydria, and decreased pepsinogen I and gastrin, thereby presenting an histological picture of chronic type A gastritis (autoimmune) [105]. The lack of intrinsic factor, which occurs as result of these changes in the gastric mucosa, reduces the absorption and transport of vitamin B12 that comes from the diet. Chronic atrophic gastritis, induced immunologically, evolves over a period of 10–30 years, until reaching gastric atrophy and the development of pernicious anemia, to the extent that the stores of vitamin B12 are depleted [105]. Vitamin B12 deficiency, parallel to the development of pernicious anemia, causes peripheral neuropathy and lesions in the posterior and lateral columns of the spinal cord, known as subacute combined degeneration, that progresses with demyelination and axial degeneration and eventually neural death [105].
2.2.3. Management of vitamin B12 deficiency in the post-Helicobacter era
Respect to the management of vitamin B12 deficiency in the post-
A recent systematic review and meta-analysis with the aim of clarifying the association between
Before initiating treatment for a patient with vitamin B12 deficiency, an assessment of the prevalence of
After 6–8 weeks of the treatment, the infection eradication must be confirmed using a non-invasive test, ideally with 13C-urea breath test [27]. If eradication is not achieved, it is mandatory to establish a new therapy scheme until eradication is achieved. Once
Figure 2 shows a diagnostic and management algorithm of vitamin B12 deficiency in the post-
2.3. Immune thrombocytopenia (ITP)
ITP is the most frequent immunological disease in hematology [135]. The annual incidence of ITP is 5.5 per 100000 persons when the platelet count cut-off point is 100 × 109/L and 3.2 per 100000 persons when the platelet count cut-off point is 50 × 109/L [136]. The chronic form of ITP increases with age, being twice as high in people older than 60 years with respect to those younger than 60 years [136, 137], with a higher incidence in women (2:1) than in men (3:1) [138].
Primary ITP, formerly known as idiopathic thrombocytopenic purpura (ITP) and autoimmune thrombocytopenic purpura, has recently been redefined and adjusted in light of new knowledge represented in the Vicenza Consensus [139]. ITP was established as an autoimmune disorder characterized by isolated thrombocytopenia (peripheral blood platelet count below 100 × 109/L) in the absence of another possible causes or conditions related to thrombocytopenia [139]. Primary ITP diagnosis continues to be one of the exclusions due to current lack of robust clinical and laboratory parameters, with high accuracy to establish its diagnosis [139]. The main clinical concern of primary ITP is the elevated risk of bleeding; however, bleeding symptoms are not present all the time [139].
2.3.1. H. pylori and immune thrombocytopenia
The association of
In Italy, in 1998, Gasbarrini et al. presented the first series of cases demonstrating the association of
A consolidated analysis of the 40 series reported worldwide reveals a total of 2074 patients with ITP, 1410 (68.0%) of whom are
Continent | Number of series |
Number of patients with ITP | Number of |
Number of treated patients | Number |
Number of patients with platelet response (%) |
Europe | 10 [151-160] | 495 | 288 (58.2) | 242 | 222 (91.7) | 108 (48.6) |
Asia | 28 [161-188] | 1525 | 1089 (71.4) | 929 | 811 (87.3) | 472 (58.2) |
America | 2 [189, 190] | 54 | 33 (90.6) | 33 | 29 (87.9) | 24 (82.8) |
Worldwide total | 40 [151-190] | 2074 | 1410 (68.0) | 1204 | 1062 (88.2) | 604 (56.9) |
Regarding to the association of
2.3.2. Pathophysiology of secondary ITP (associated with H. pylori infection)
The origin of primary ITP is associated with congenital or acquired immune changes that lead to an immune system response against platelets or megakaryocytes that cannot be attributed to other causal changes. In secondary ITP, alternative primary events are identified that lead to the development of this autoimmune response [209]. In the case of
In conjunction with the overeactivation of monocytes, autoantibody production has also been described in ITP, which can opsonize the platelets and induce antibody-mediated phagocytosis by the reticuloendothelial system in the spleen. This response is attributed to molecular mimicry of infection-related bacterial proteins. The principal antigens associated with the autoimmune response against the platelets include the amino acid sequences of virulence factors such as VacA, CagA [17, 178] and urease B, which are present during
2.3.3. Management of ITP in the post-Helicobacter era
Concerning to the management of ITP in the post-
The American Society of Hematology (ASH) recognized
Before initiating treatment for a patient with ITP, an assessment of the prevalence of
After 6–8 weeks of treatment, the infection eradication must be confirmed using a non-invasive test, ideally with 13C-urea breath test [27]. If eradication is not achieved, it is mandatory to establish a new therapy scheme until eradication is achieved. Once
Figure 3 shows a diagnostic and management algorithm for ITP in the post-
3. Hematological diseases not recognized as related to H. pylori
This group includes autoimmune neutropenia, antiphospholipid syndrome, Henoch–Schönlein purpura, plasma cell dyscrasias, such as monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma, and other diseases possibly associated or implicated, such as leukemia and hemorrhagic manifestations with hematologic origin, like congenital and acquired coagulopathies and anticoagulation.
3.1. Immune neutropenia
This association was first proposed in 2002 by Gupta et al. in England, who reported the case of a patient with neutropenia (400 neutrophils/µL) that rapidly returned to normal values following the eradication of
3.2. Antiphospholipid syndrome
Similarly to immune neutropenia, antiphospholipid syndrome, a coagulation disorder of immunologic origin characterized by both arterial and venous thrombosis and associated with pregnancy complications, such as abortion, premature childbirth, and pre-eclampsia [217], was proposed as an extragastric association of
3.3. Henoch–Schönlein purpura
Henoch–Schönlein purpura is an immunologic disease of unknown etiology manifested by small vessel leukocytoclastic vasculitis with deposits of immunoglobulin A (IgA) in the skin, joints, gastrointestinal tract, and kidneys [224]. Henoch–Schönlein purpura is included in this review because it is part of the differential diagnosis of thrombocytopenia, particularly ITP discussed previously, which manifests as purpuric lesions on the skin. The association of
3.4. Plasma cell dyscrasias
Plasma cell dyscrasias are among the most frequent clonal diseases in elderly persons and include MGUS, multiple myeloma, solitary plasmacytoma, plasma cell leukemia, Waldenström’s macroglobulinemia, and other chronic myeloproliferative syndromes of B lymphocytes [234]. Plasma cell dyscrasias may present an asymptomatic course or pass from one disease to another; for example, MGUS, a completely benign and asymptomatic condition that does not require treatment, can transform into a more severe and potentially fatal disease, such as multiple myeloma [234].
The association of plasma cell dyscrasias with stomach diseases has been known for many years, before the discovery that the stomach could be colonized by bacteria [3]. Gastrointestinal plasmacytomas were documented by the father of modern medicine, Sir William Osler, in 1920 [235], and for many years, the association of these and multiple myeloma with pernicious anemia [236, 237] and gastric cancer [238-242], entities clearly correlated with
The relation of multiple myeloma with gastric MALT type lymphomas [248-254] was identified many years before
According to Malik et al., MGUS, important in the study of patients with plasma cell dyscrasia, may be related to
3.5. Other hematologic manifestations
According to the medical literature, other hematologic manifestations demonstrate possible associations with
Another problem emerging in clinical practice is the inherent increased risk of hemorrhage in patients with hematologic diseases;
4. Conclusions
The recognition of hematologic diseases associated with
4.1. Iron deficiency
The management of iron deficiency is palliative and based on iron supplementation [32], where there is often no impact on the direct cause associated with ferropenia [35]. With the incorporation of iron deficiency, with or without anemia, into the consensus and management guides for
4.2. Vitamin B12 deficiency
The management of vitamin B12 deficiency is also palliative and based on vitamin supplementation, where there is little impact on the initial cause of the deficiency [134]. With the incorporation of vitamin B12 deficiency into the consensus and management guides for
4.3. Immune thrombocytopenia
The treatment of ITP is palliative, not curative, and is oriented toward controlling the production of antibodies against platelets using medication or through the removal of organs that sequester platelets, such as the spleen [140, 209]. With the incorporation of ITP into the consensus and management guides for
Acknowledgments
The author gratefully acknowledges to Verónica Tangarife-Castaño for her insightful discussions and help with the English translation as well as the willingness and collaboration.
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