الفهرس 
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Abstract
Immune thrombocytopenic purpura (ITP), also known as idiopathic thrombocytopenic purpura , is an autoimmune bleeding disorder characterized by bleeding due to isolated thrombocytopenia with a normal bone marrow in the absence of other causes of low platelets . [Marini I and BakchoulT 2019 ]. It causes a characteristic red or purple bruise-like rash and an increased tendency to bleed. [Matzdorff A et al 2018 ] .
The exact mechanism of autoimmunity leading to ITP is still unclear. Under non-pathological conditions the immune system is finely regulated by humoral and cellular components, including primarily regulatory T and B cells (T regs and B regs). , alteration of the balance between these regulatory cells and effectors results in a breakdown of the immune tolerance causing increased platelet clearance and impaired thrombopoiesis.
Similarly to other autoimmune disorders, molecular mimicry with bacterial or viral proteins might be one reason for pathogenesis of ITP. In fact, it was reported a cross-reactivity of anti-platelet autoantibodies with human immunodeficiency virus, hepatitis C virus and Helicobacter pylori in secondary ITP.[Maini I et al 2019 ] [Ku FC et al 2013 ]
Helicobacter pylori (i.e. H. pylori), previously known as Campylobacter pylori, is a Gram-negative, helically-shaped, microaerophilic bacterium usually found in the stomach. [Alfarouk et al 2019 ] . Its helical shape (from which the genus name, helicobacter, derives) is thought to have evolved in order to penetrate the mucoid lining of the stomach and thereby establish infection.[ Yamaoka et al 2008 ] and causes mainly chronic gastritis and gastric ulcer .
Many investigators have proposed causal associations between H. pylori and a wide range of other diseases (e.g. idiopathic thrombocytopenic purpura, iron deficiency anemia, atherosclerosis, Alzheimer’s disease,[ Laird-Fick HS et al 2016 ]
Many studies had found obvious relation between helicobacter pylori infection and chronic idiopathic thrombocytopenic purpura ; Several studies have reported remission of immune thrombocytopenic purpura ( ITP) after eradication of a coexistent Helicobacter pylori infection in adults. Data in children are limited. Here we reported the results of a prospective study of Helicobacter pylori determination and eradication in children with chronic ITP .
This study was conducted on 83 chronicidiopathic thrombocytopenic purpura childen with age range from 3 to 13 years that include 46 males 37 females .Also the study included 104 healthy individual with the same range of age that include 58 males and 46 females as a control group . This was between October , 2018 and September, 2019 in the Pediatric haematology and GIT Clinics or inpatients wards of Pediatric Department .
Our aim in this study to estimate prevalence of h.pylori infection among chronic ITP pediatric patients and comparing it to the one among healthy children . Also conclude the association between h.pylori infection and ITP by evaluating the effect of eradication of infection on PLT count in ITP pediatrics .All children in our study were subjected to complete clinical examination , investigations including ; PLT count and H.pylori antigen in stool.
We performed a clinical analysis and reviewing the data of the 83 children with chronic ITP and the 104 healthy group , with special consideration for the age, sex, BMI, age at diagnosis, treatment received , and both groups were subjected to complete clinical examinations, investigations including; platelet count and H.pylori antigen in stool .
In this study 83 cases of patients group and 104 cases of control group were screened for H. pylori infection. The prevelance of H.pylori was 66.2% ( 55 cases) among patients group and 29.8% (31 cases ) among control group .The prevelance was markedly highier in patients group which supported the association between H.pylori infection and ITP.
All cases that had H. pylori positive test were treated with a combination of amoxicillin 50 mg/kg/d, clarithromycin 10 mg/kg /d. and omeprazol 1 mg/kg /d for two weeks. Eradication success was assessed 6 weeks after the end of treatment using the stool antigen test ;47 cases( 85.4 % ) successfully treated and showed negative result while the other 8 cases of the patients group showed positive test.
In our study platelet counts were determined after one month of successful eradication of H.pylori infection of patients group and then after 6 months . Eradication was defined as a complete response if the PLT count was greater than 150 × 109/L and a partial response if it was at least 50 × 109/L with an increase of more than 30 × 109/L over the basal count. No response was defined as a PLT count of less than 50 × 109/L, a lack of a more than 30 × 109/L increase , or the need for maintenance therapy.
After one month the 47 cases who were successfully treated from H.pylori infection tested for platelet count and showed platelet mean± SD 76.65 ± 16.57; 20 cases (46.6 %) had partial response ,while 27 cases (57.4 % ) had no response . On the other hand the 8 cases with non successfully eradication had platelet mean± SD 65 ± 12.6; (87.5 % ) 7 cases of them showed no response and 1(12.5 %) case showed partial response.
Then after 6 monthes there was marked increase in platelet count in successfully treated group with platelet mean± SD 95.57 ± 29.85 ; 25cases ( 53.5% ) group showed partial response, 6 cases (12.7 %) showed complete response ,and 16 cases (34 % ) showed no response .While in non successfully treated group there was no change in platelet response with platelet mean± SD 70 ± 31.61 ; 87.5 % of them still had no response and 12.5% still had partial response . Furthermore none of them showed complete platelet response . So there was no significant response in platelet count in non successfully treated group , which was in agreement with previous reports showing that an ITP response occurs only among patients with successful eradication and not among those with unsuccessful H.pylori eradication .
The higher prevelance of H.pylori infection among cITP children and the significant increase in platelet count after H.pylori eradication suggests a role of H. pylori in cITP disease .Maybe H.pylori infection does not play a primary role in the onset and / or persistence of ITP , but it may have an additional effect on the thrombocytopenia in ITP while not being the sole cause .
Clinical benefit occurred in 31 cases of the 83 cITP patients screened; nevertheless, we have a simple, inexpensive, non‐invasive screening method; the adverse events of eradication therapy are negligible, together with an affordable cost, all uncommon attributes among the specific treatments currently available for cITP; therefore it is worthwhile to test for and treat H. pylori infection.
In conclusion , our data showed a prevelance of H.pylori infection in cITP pediatrics that was similar to another studies . we found that successful H.pylori eradication induced platelet response in 37.3 % of 83 cases included in our study.
Even if a causative role for H.pylori infection cannot be demonstrated ,the availability of a safe , tolerable , and in expensive method for detecting and treating H.pylori suggests that it may be appropriate to investigate and eradicate H.pylori infection in cITP children.