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An unusual immune thrombocytopenia case associated with dietary supplements containing 3G (Green tea, Ginseng and Guarana)

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Abstract

Immune thrombocytopenia (ITP) is caused by autoantibodies to platelet antigens. Ginseng, a herbal remedy, inhibits platelet aggregation as well as green tea and guarana. We present a case of secondary ITP due to food supplement that contains ginseng, guarana and green tea, which is not previously reported in medical literature. A 39-year-old man was admitted to our clinic because of 2 days history of oral mucosal hemorrhage and recently developed skin lesions on extensor surfaces of bilateral upper extremity and both ankles. Platelet count was 5,470/mm 3. He was diagnosed with secondary ITP, possibly due to herbal supplement contained green tea, ginseng and guarana, which patient was received for 4-5 days about 1 month ago. He responded well to the treatment with methyl prednisolone. Since herbal medicines and dietary supplements have many toxic effects it should be kept in mind that secondary ITP may develop during supplementation with these herbal products.
ISSN 2304-3415, Russian Open Medical Journal
1 of 3
2020. Volume 9. Issue 3 (September). Article CID e0307
DOI: 10.15275/rusomj.2020.0307
Clinical Nutrition
[
© 2020, LLC Science and Innovations, Saratov, Russia
www.romj.org
Case report
An unusual immune thrombocytopenia case associated with dietary supplements containing 3G
(Green tea, Ginseng and Guarana)
Mehmet Zahid Kocak, Gulali Aktas, Satilmis Bilgin, Tuba T. Duman, Ozge Kurtkulagi, Burcin Atak,
M. Emin Demirkol, Elif Bulut Yilmaz
Abant Izzet Baysal University Hospital, Department of Internal Medicine, Bolu, Turkey
Received 19 December 2019, Revised 2 March 2020, Accepted 15 July 2020
© 2019, Kocak M.Z., Aktas G., Bilgin S., Duman T.T., Kurtkulagi O., Atak B., Demirkol M.E., Yilmaz E.B.
© 2019, Russian Open Medical Journal
Abstract: Immune thrombocytopenia (ITP) is caused by autoantibodies to platelet antigens. Ginseng, a herbal remedy, inhibits platelet
aggregation as well as green tea and guarana. We present a case of secondary ITP due to food supplement that contains ginseng, guarana
and green tea, which is not previously reported in medical literature. A 39-year-old man was admitted to our clinic because of 2 days
history of oral mucosal hemorrhage and recently developed skin lesions on extensor surfaces of bilateral upper extremity and both ankles.
Platelet count was 5,470/mm3. He was diagnosed with secondary ITP, possibly due to herbal supplement contained green tea, ginseng and
guarana, which patient was received for 4-5 days about 1 month ago. He responded well to the treatment with methyl prednisolone. Since
herbal medicines and dietary supplements have many toxic effects it should be kept in mind that secondary ITP may develop during
supplementation with these herbal products.
Keywords: secondary ITP, ginseng, guarana, green tea, thrombocytopenia.
Cite as Kocak MZ, Aktas G, Bilgin S, Duman TT, Kurtkulagi O, Atak B, Demirkol ME, Yilmaz EB. An unusual immune thrombocytopenia case associated with
dietary supplements containing 3G (Green tea, Ginseng and Guarana). Russian Open Medical Journal 2020; 9: e0307.
Correspondence to Mehmet Zahid Kocak. Address: Abant Izzet Baysal University Hospital, Department of Internal Medicine, Golkoy, 14200, Bolu, Turkey.
Phone: +903742534656. Fax: +903742534615. Email: mehmetzahidkocak@hotmail.com.
Introduction
Immune thrombocytopenia (ITP) is an acquired
thrombocytopenia caused by autoantibodies to platelet antigens
[1]. Primary ITP is defined when isolated thrombocytopenia
(platelet count <100x 109/L) was present in the absence of other
causes that may be associated with thrombocytopenia [1]. On the
other hand, secondary ITP is defined as immune
thrombocytopenia driven by any other cause. Hepatitis C virus [2],
Cytomegalovirus (CMV), Epstein Barr virus (EBV), human
immunodeficiency virus (HIV), varicella zoster virus (VZV) [3],
various vaccines [4] and certain drugs [5] are among the causes of
secondary ITP.
Ginseng, a herbal remedy, inhibits platelet aggregation [6].
Similarly, green tea [7] and guarana [8], which are common in
dietary supplements also affect platelet functions. However, food
supplements containing ginseng, guarana and green tea have been
reported to cause thrombocytopenia, too [8].
In this article, we aimed to present a case of secondary ITP due
to food supplement that contains ginseng, guarana and green tea,
which is not previously reported in medical literature.
Clinical Case
A 39-year-old man was admitted to our clinic because of 2
days history of oral mucosal hemorrhage and recently developed
skin lesions on extensor surfaces of bilateral upper extremity and
both ankles. The patient's medical history was unremarkable and
there was no history of drug use. The patient used a complex food
supplement containing green tea, ginseng and guarana for 4-5
days as food supplement about 1 month ago. Rest of the medical
history was unremarkable.
The vital signs of the patient were as follows: arterial blood
pressure 110/70 mmHg, heart rate 60 beats/minute, body
temperature 36.7 celcius degree and respiration rate 16/minute.
Physical examination revealed intra-oral bullae, petechiae lesions
on extensor surfaces of both upper extremity and on both ankles,
and ecchymosis with a 2x4cm diameter on the right axillary region.
There were also petechiae on the skin of the abdomen.
Laboratory analyses revealed that white blood cell count was
10400/mm3, hemoglobin was 15.7 g/dL, hematocrit was 47%,
platelet count was 5,470/mm3. Serum vitamin B12 level was 300
ng/L, folic acid level was 6.5 pg/L, and ferritin was 145 pg/L.
Platelet count in blood smear was counted as 5,000/mm3, without
any atypical cells and any abnormalities in erythrocytes.
Prothrombin time (PT), partial thromboplastin time (aPTT) and
INR of the patient were normal. Hepatitis serology panel and anti-
HIV antibody were negative. EBV IgM and CMV IgM were negative.
Helicobacter pylori antigen was negative in stool analysis. Thyroid
function tests were within normal range and anti-thyroid
autoantibodies were negative. Similarly anti-nuclear antibody was
ISSN 2304-3415, Russian Open Medical Journal
2 of 3
2020. Volume 9. Issue 3 (September). Article CID e0307
DOI: 10.15275/rusomj.2020.0307
Clinical Nutrition
[
© 2020, LLC Science and Innovations, Saratov, Russia
www.romj.org
negative. Abdominal sonography was not detected any
abnormalities, including splenomegaly.
A diagnosis of secondary ITP was established according to the
clinical features and laboratory tests. He was started on
prednisolone 80 mg/day. Daily hemogram count and peripheral
smear were followed-up. Pulse steroid treatment (1g methyl
prednisolone daily, for 3 days) was initiated since the platelet
count decreased to a critical level of 3,000/mm3 during clinical
follow-up. It reached up to 11,000/mm3 with pulse steroid
treatment. Then, the prednisolone dose was reduced to 80
mg/day. Subsequently, the platelet count increased to
86,000/mm3 on the 8th day of hospitalization.
Since his complaints were diminished and platelet count rose
to a relatively safe level, the patient was referred to the
hematology department with full recovery. His platelet counts
were remained in normal range in his control examinations.
Discussion
In this case report, we present a young man diagnosed with
secondary ITP due to dietary supplementation which includes 3Gs
(green tea, ginseng and guarana). To the best of our knowledge,
there are no other cases of ITP related to ginseng, guarana and
green tea complex in the literature.
Immune thrombocytopenia is a common hematological
disease affecting individuals of all races, ages and genders. While
ITP affects more men in childhood, it affects more women in the
young population. Its incidence increases by aging. The rate of ITP
in men and women in the elderly population is similar [9]. 80% of
ITP cases are idiopathic and 20% occur by secondary causes [10].
Secondary ITP often develops after infection. However, the patient
presented had no previous infection. It has been reported that ITP
may develop as a result of Helicobacter pylori, CMV, VZV, hepatitis
C virus and HIV infections [3]. In our patient, hepatitis panel, other
viral agents and helicobacter pylori were all negative. Therefore,
no ITP secondary to infection was considered.
Prescription and non-prescription drug use, including herbal
medicine and food supplements, may cause secondary ITP [11].
Our patient did not have any history of drug use, recently.
However, he consumed green tea, ginseng and guarana complex
which was used as food supplement for the last 1 month. These 3
components have been reported to affect platelet numbers and
functions [6-8]. Green Tea inhibits thrombogenesis by inhibiting
platelet aggregation with its catechin [7]. Similarly, ginseng and
guarana also inhibit platelet aggregation [6,8]. Causes of
Secondary ITP include herbal remedies and food supplements.
Therefore we established the diagnosis of secondary ITP in present
case which was driven by dietary supplements.
Recently, the use of herbal remedies and food supplements as
alternative medicine is increasing. Many side effects and toxicities
arise during the usage of these herbal remedies and food
supplements. These include hepatotoxicity, renal injury, allergic
skin reactions, hypertension and bleeding [12]. However, we have
reported that even secondary ITP may be associated with these
substances, as in presented patient. Secondary ITP is an important
hematological disease characterized by petechiae and
ecchymoses. Secondary cause of ITP should be removed in sake of
successful treatment. However, corticosteroid therapy may be
necessary in cases with very low platelet counts. In our case, a
medium dose of steroid was given because of low platelet levels
both in hemogram and blood smear. In cases where platelet levels
do not increase despite medium dose steroids, high dose steroids,
intravenous immunoglobulin and anti-D could be alternative
treatment choices and platelet suspension may be given in life-
threatening situations. In present case, platelet levels did not
increase with medium dose steroid therefore, pulse steroid
treatment initiated and platelet count was increased after this
treatment. Since he did not start on herbal medicine that include
green tea, ginseng and guarana, he did not suffer from
thrombocytopenia during his clinical follow up. Therefore, we
assume that immune thrombocytopenia in present case could be
driven by the use of herbal medicine that include green tea,
ginseng and guarana.
Conclusion
Since herbal medicines and dietary supplements have many
toxic effects it should be kept in mind that secondary ITP may
develop during supplementation with these herbal products.
Conflict of Interest
Authors declare that they have no conflict of interest to disclose.
Informed Consent
The patient presented in this case report was given informed consent
for this study.
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2020. Volume 9. Issue 3 (September). Article CID e0307
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© 2020, LLC Science and Innovations, Saratov, Russia
www.romj.org
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Authors:
Mehmet Zahid Kocak MD, Associate Professor, Department of Internal
Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0003-3085-7964.
Gulali Aktas MD, Associate Professor, Department of Internal Medicine,
Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0001-7306-5233.
Satilmis Bilgin MD, Assistant Professor, Department of Internal Medicine,
Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0003-2811-0052.
Tuba T. Duman MD, Assistant Professor, Department of Internal
Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0002-3836-2125.
Ozge Kurtkulagi MD, Assistant Professor, Department of Internal
Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0002-4162-5563.
Burcin Atak MD, Assistant Professor, Department of Internal Medicine,
Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0003-4201-9757.
M. Emin Demirkol MD, Assistant Professor, Department of Internal
Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0001-6262-6103.
Elif Bulut Yilmaz MD, Assistant Doctor, Department of Internal Medicine,
Abant Izzet Baysal University Hospital, Bolu, Turkey.
https://orcid.org/0000-0002-6402-6491.
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