الفهرس 
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Abstract
Over the past decades, a wealth of information has been reported about the pathogenic features of ITP. To this day, however, it is unclear whether the immune abnormalities associated with ITP play causative roles in the disease or are secondary epiphenomena brought on by the inflammatory processes that are associated with the disorder. ITP is a heterogeneous autoimmune disorder characterized by thrombocytopenia with or without mucocutaneous bleeding manifestations.
Immune thrombocytopenia is mediated by platelet antibodies that accelerate platelet destruction and inhibit their production. The dominant clinical manifestation is bleeding, which correlates generally with severity of the thrombocytopenia.
Concepts surrounding the mechanisms of thrombocytopenia in ITP have shifted from the traditional view of increased platelet destruction mediated by auto-antibodies to more complex mechanisms in which impaired platelet production, T-cell-mediated effects, and disturbed cytokine profiles play a role.
Interleukin-21 is an IL-2 family cytokine produced by activated T cells to regulate immune responses. IL-21 is strongly linked with inflammation and autoimmunity. The chemokine C-X-C motif chemokine 13 (CXCL13) is necessary for follicle formation and is constitutively expressed in secondary lymphoid tissue, primarily by FDCs. C-X-C chemokine receptor type 5 (CXCR5), the only known receptor for CXCL13, is expressed by naïve B cells and TFH cells, and it controls the migration of these cells to the follicle.
In the present study; we aimed at measuring the plasma levels of IL-21 and CXCL-13 in adult patients with ITP and the effect of corticosteroid treatment on their levels, thus trying to find out if they have any prognostic value in ITP.
Our study included 30 adult ITP patients attending the Hematology Outpatient Clinic, Alexandria Main University Hospital, and 30 healthy controls matched for age and sex. All patients had newly diagnosed primary ITP, and all causes of secondary ITP were excluded.
Thorough history taking, full clinical examination and laboratory investigations were performed to all included patients at the time of diagnosis. Sample collection was done before receiving therapy then all patients received prednisolone 1-2 mg/kg as first line therapy for two to four weeks with monitoring of the platelet levels after receiving treatment. A second blood sample was taken from each patient after 1 month from diagnosis.
Plasma IL-21 and CXCL-13 levels were measured twice, first at diagnosis and second after one month of corticosteroid therapy. All results were tabulated and statistically analyzed.
The results of our study showed that the mean age of ITP patients was 33.80±8.352 years, there was statistically significant higher percentage of females than males (X2=21.696, p=0.000*), with a female: male ratio of 3:1.
Regarding the clinical data, 27 patients presented with bleeding manifestations and 3 were accidentally diagnosed during routine investigation. Within the 27 patients, bleeding manifestations varied between menorrhagia (43.33%), ecchymosis on minor trauma (36.67%), epistaxis(20%), melena (10%), gingival bleeding (6.67%), subconjunctival hemorrhage (3.33%) and one patient presented with intracranial hemorrhage (3.33%).
Regarding the complete blood picture, hemoglobin level ranged from 5 to 15 g/dl with a mean of 11.5±2.200 g/dl, with a statistically significant increase in hemoglobin levels in male when compared to the female patients (Z=2.797, p=0.003). In our study; 14 patients suffered from anemia: 10 (33.33%) had mild anemia (grade 1), 3 (10%) patients had moderate anemia (grade 2) and only 1 (3.33%) patient had life threatening anemia (grade 4).
On measuring IL-21and CXCL-13 plasma levels at diagnosis, results showed statistically significant higher levels of IL-21 and CXCL-13 in ITP patients compared to the healthy controls (p=0.012). While on comparing their levels before and after treatment, they showed statistically significant lower levels after treatment (Z=4.703, p=0.000 and Z=4.788, p=0.000; respectively).
Based on our results we concluded that IL-21 and CXCL-13 play a role in the pathogenesis of ITP. Also corticosteroids play a role in modulating their levels.IL-21 and CXCL-13 may be used as predictors of disease response to corticosteroids, however, further studies should be taken on wider scales and using different protocols of treatment to figure out the exact role of IL-21 and CXCL-13 in ITP.