Thrombotic thrombocytopenic purpura as a cause of pancreatitis. Report of a case and review of the literature

Acute pancreatitis-induced thrombotic thrombocytopenic purpura with recurrent acute pancreatitis

Recent successive reports on acute pancreatitis-induced thrombotic thrombocytopenic purpura (TTP) have revealed that TTP-related microvascular damage is an aggravating factor of acute pancreatitis. Here, we report the case of a 26-year-old man diagnosed with acute pancreatitis due to high alcohol consumption. The patient was unconscious as he had taken an overdose of medication, and presented with fever and renal failure due to acute pancreatitis on admission. Although the pancreatitis subsequently improved, the symptoms were still observed; on the next day, he exhibited hemoglobinuria, anemia, and thrombocytopenia. Moreover, general blood examinations indicated the presence of schistocytes and reduced activity of ADAMTS13 (a disintegrin-like metalloproteinase with thrombospondin type 1 motif 13) to 47 %. Thus, the patient was diagnosed with TTP, and plasma exchange was performed. After the development of TTP, the acute pancreatitis recurred, but a severe pathogenesis was prevented by plasma exchange. Thus, ADAMTS13 activity may be useful for predicting a severe pathogenesis of acute pancreatitis. In ADAMTS13-deficient cases, plasma exchange may be an effective technique for preventing aggravation of acute pancreatitis.

[Acute pancreatitis and thrombotic microangiopathy: a two-way association]

Acute pancreatitis and thrombotic microangiopathy is an established association: but which is the cause, which is the consequence? Thanks to two case reports and a literature review, we put to light an unequivocal link. Indeed, thrombotic microangiopathy may be responsible for ischemic pancreatitis. On the other hand, acute pancreatitis, whatever its cause, may trigger thrombotic microangiopathy. In either case, an anti-ADAMTS-13 antibody can be detected: its research is mandatory.

Lessons from acute pancreatitis-induced thrombotic thrombocytopenic purpura

Acute pancreatitis is an inflammatory disease characterized by local tissue injury which can trigger a systemic inflammatory response. There is increasing evidence that endothelial dysfunction is one of the critical pathophysiologic manifestations in patients with severe form of acute pancreatitis. In keeping with this, there have been recent reports of a haematological disorder, thrombotic thrombocytopenic purpura (TTP), as being precipitated by acute pancreatitis. However, the patients who develop TTP, secondary to acute pancreatitis, do not always have the characteristic low levels of VonWillebrand multimer cleaving enzyme, ADAMTS-13 suggesting the involvement of other pathophysiological factors. On the contrary, the occurrence of acute pancreatitis in haemolytic diseases may suggest TTP as being a precipitating factor for the pancreatic inflammatory state. This review focuses on the association of these two conditions which have given insights into the role players and the pathogenic mechanisms leading to the development of either of these conditions.

Plasma ADAMTS13 activity parallels the APACHE II score, reflecting an early prognostic indicator for patients with severe acute pancreatitis

OBJECTIVE

Severe acute pancreatitis (SAP) frequently progresses to pancreatitis-associated multiorgan failure (MOF) with high mortality. Decreased plasma ADAMTS13 activity (ADAMTS13:AC) results in the accumulation of unusually large von Willebrand factor multimers (UL-VWFM) and the formation of platelet thrombi, ultimately leading to MOF. The purpose of the study was to investigate the potential role of ADAMTS13:AC in the severity of SAP.

MATERIAL AND METHODS

Plasma ADAMTS13:AC and its related parameters were sequentially determined in 13 SAP patients. ADAMTS13:AC was determined by the chromogenic act-ELISA.

RESULTS

Within 1 or 2 days after admission, ADAMTS13:AC was lower in SAP patients (mean 28%) than in healthy controls (99%), and gradually recovered in the 11 survivors but further decreased in the 2 non-survivors. Patients with higher sepsis-related organ failure assessment (SOFA) scores showed lower ADAMTS13:AC than those without these scores. The inhibitor against ADAMTS13 was undetectable. On day 1, von Willebrand factor antigen (VWF:Ag) was higher (402%, p<0.001) in SAP patients than in controls (100%). VWF:Ag gradually decreased in the survivors, except in the 3 patients needing a necrosectomy, but remained high in the non-survivors. ADAMTS13:AC was inversely correlated with the APACHE II score (r=-0.750, p<0.005), and increased plasma concentrations of interleukin 6 (IL-6) and IL-8 at admission. UL-VWFM-positive patients had lower ADAMTS13:AC and decreased serum calcium concentrations, but higher VWF:Ag and IL-8 concentrations than UL-VWFM-negative patients.

CONCLUSIONS

Plasma ADAMTS13:AC was closely related to the APACHE II score. This intimate relationship may serve as an early prognostic indicator for SAP patients. The imbalance between decreased ADAMTS13:AC and increased UL-VWFM could contribute to SAP pathogenesis through enhanced thrombogenesis.

Thrombotic thrombocytopenic purpura associated with severe acute pancreatitis in a context of decreased ADAMTS13 activity: a case report

Thrombotic thrombocytopenic purpura (TTP) is a severe multisystemic microvascular disease defined by the association of hemolytic anemia, thrombocytopenia, acute renal failure, fever, and neurological disorders. The pathophysiology has recently been elucidated by the discovery of a von Willebrand factor-cleaving protease (ADAMTS13) deficiency involved in platelet aggregation and ischemia. The association between TTP and acute pancreatitis (AP) has rarely been reported, described either as a cause or a consequence. The role of ADAMTS13 during AP is still unknown. We describe the case of a 41-year-old woman who developed a TTP, with decreased ADAMTS13 activity, associated with severe AP. Published cases of thrombotic microangiopathy associated with AP are reviewed. The pathophysiology, management, prognostic factors, and rationale for treatment are discussed. AP should be sought in patients with TTP presenting with abdominal pain. On the other hand, TTP should be considered in patients with AP and thrombocytopenia.

Thrombotic Thrombocytopenic Purpura: aetiology, pathophysiology and treatment

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder whose varied clinical manifestations result from the formation of platelet-rich thrombi within the microvasculature and consequent tissue ischaemia. This review will outline how, in the eighty years since its initial description, scientific discoveries have not only led to a deeper understanding of the fundamental pathophysiology of TTP, but have also contributed to advances in the clinical management of this condition. Current research in this field will hopefully provide the basis for the design and development of novel therapeutic strategies.

DIC secondary to acute pancreatitis

Various hematological abnormalities including fall in serial values of hemoglobin or hematocrit, coagulation factor abnormalities, leukocytosis, acute hemolytic anemia, thrombocytopenia, and thrombotic thrombocytopenic purpura or hemolytic uremic syndrome have been reported in patients with acute pancreatitis. Similarly, abnormalities of blood coagulation factors consistent with disseminated intravascular coagulopathy (DIC) have also been noticed in patients with pancreatitis. We report a case of a 33-year-old female with acute pancreatitis who presented with one episode of epistaxis and abnormal prothrombin time and partial prothrombin time. Coagulation work-up revealed thrombin time 24.3 s fibrinogen 110 mg/dl, D-dimers >1 and < 2, and fibrin degradation products >22. Pancultures did not show any evidence of infection. The patient maintained a normal renal and mental status during her illness. Her D-dimers continued to decrease with resolution of acute pancreatitis as evidenced by decreased abdominal pain, relief of nausea, control of vomiting, and decrease in serum amylase and lipase levels. This case report suggests that coagulation abnormalities are encountered in patients with acute pancreatitis. It is hypothesized that such hemostatic abnormalities may be related to early intravascular consumption of coagulation factors secondary to circulating pancreatic enzymes, particularly trypsin, or secondary to vascular injury. Recognition of these hematological complications including DIC is paramount. Physicians caring for these patients should be aware of such a complication of acute pancreatitis.

A case study of thrombotic thrombocytopaenic purpura: a 'powerful poison'

This paper presents the case of a previously well 72 year old man who spent 86 days in the intensive care unit (ICU) following a remarkable and explosive presentation of the rare condition thrombotic thrombocytopaenic purpura (TTP). TTP is an intravascular platelet aggregation disorder that, without treatment, is associated with significantly high mortality rates. This paper discusses TTP in terms of its presentation, pathophysiology, diagnosis and management. In addition to TTP, the patient developed a number of comorbidities during his stay in ICU. Particular attention is given to two major problems: acute renal failure and prolonged encephalopathy. These issues, along with the initial diagnosis of TTP, resulted in the patient remaining in ICU for a longer period than otherwise might have been expected. Despite many obstacles, the patient recovered and was discharged from hospital 116 days after initial presentation.

Thrombotic microangiopathy: an atypical cause of acute renal failure in patients with acute pancreatitis

OBJECTIVE

To report on the development and treatment of thrombotic microangiopathy, an atypical cause of acute renal failure in patients with acute pancreatitis.

DESIGN

Case reports.

SETTING

A 21-bed medical intensive care unit at an university hospital.

PATIENTS

Two men with acute pancreatitis presented with acute renal failure, neurological manifestations, haemolytic anaemia and thrombocytopenia. Both patients required intensive care.

MEASUREMENTS

Fragmented red cell count; levels of haptoglobin, amylase and lipase; serological testing for Escherichia Coli O157; computed tomography of the abdomen.

MAIN RESULTS

The patients' courses were rapidly favourable after daily plasma exchange. A review of the existing medical literature was also undertaken.

CONCLUSION

As thrombotic microangiopathy may be life-threatening without administration of fresh frozen plasma or plasma exchange, physicians should consider this disease as a possible cause of acute renal failure in patients with acute pancreatitis.

Pancreatitis leading to thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case report and review of literature

Pancreatitis is a well-established but unusual complication of thrombotic thrombocytopenic purpura (TTP). It is also an unusual complication of systemic lupus erythematosus (SLE). However, TTP occurring as a consequence of acute pancreatitis in a patient with SLE has never been reported. We report a 24-year-old African American woman with active systemic lupus (SLE) who developed thrombotic thrombocytopenic purpura (TTP) following an episode of acute pancreatitis. The TTP was manifested by low-grade fever, microangiopathic hemolytic anemia, renal insufficiency, altered mental status, seizures and thrombocytopenia. The patient was initially treated with pulse corticosteroids with inadequate response and subsequently with daily plasmaphresis, leading to full remission. This case represents first report of pancreatitis leading to TTP in a patient with systemic lupus erythematosus.

Thrombotic thrombocytopenic purpura (TTP) presenting as pancreatitis

Thrombotic thrombocytopenic purpura (TTP) is a rare clinical entity. It is a multi-systemic disorder characterized by a clinical pentad of thrombocytopenia, microangiopathic hemolytic anemia, diffuse and nonfocal neurologic symptoms, decreased renal function, and fever. Abdominal pain is an uncommon presenting symptom for TTP. Pancreatitis may occur from TTP or, in a few cases, may trigger TTP. The clinical diagnosis of TTP is generally difficult because there are many varied clinical presentations and the full expression of the pentad may be prolonged. However, once the diagnosis is suspected or confirmed, immediate plasmapherseis with plasma exchange must be performed to reduce the severe morbidity from neurologic disability.

Recurrent thrombotic thrombocytopenic purpura (TTP) as a complication of acute relapsing pancreatitis

Pancreatitis is a known complication of thrombotic thrombocytopenic purpura (TTP) found in approximately 2% of cases. The development of TTP as a clinical sequelae of acute pancreatitis has also been reported, including one patient with chronic pancreatitis who developed TTP on two occasions following acute exacerbations of pancreatitis. We describe a case in which multiple distinct episodes of TTP have followed the clinical and laboratory demonstration of acute pancreatitis in the same patient. Supportive care of the patient's pancreatitis and plasmapheresis in each case resulted in clinical improvement and resolution of TTP. While the pathophysiologic mechanism explaining this association remains unclear, the recurrence of TTP associated with the "rechallenge" of relapsing episodes of pancreatitis in our patient suggests that a cause-and-effect relationship does exist.

Various clinical manifestations in patients with thrombotic microangiopathy

BACKGROUND

Thrombotic microangiopathy (TM) is characterized by thrombocytopenia and microangiopathic hemolytic anemia in association with diffuse microthrombi in the arteriolar capillaries of various organs. Its clinical manifestation is protean, and a few well-defined clinical syndromes have been recognized. A clear understanding of the consequence of TM is needed to appreciate the unusual clinical syndromes due to atypical presentation of thrombotic thrombocytopenic purpura (TTP).

METHODS

The medical records of patients with known diagnoses of TTP, hemolytic uremic syndrome (HUS), and the syndrome in which hemolysis, elevated liver enzymes, and low platelet count are found in association with pregnancy were examined retrospectively from 1981 to 1994 and prospectively from 1995 to 2000. Various thrombotic microangiopathic presentations were identified in these patients. Their response to exchange plasmapheresis was evaluated, and their clinical outcome was determined.

RESULTS

A total of 74 patients were diagnosed with TM. Among these patients, several well-defined thrombotic microangiopathic presentations were identified. These presentations included TTP in 57 patients, acute respiratory distress syndrome (ARDS) in 13 patients, HUS in 9 patients, the syndrome in which hemolysis, elevated liver enzymes, and low platelet count are found in association with pregnancy in 9 patients, peripheral digit ischemic syndrome (PDIS) in 6 patients, pancreatitis in 3 patients, hepatitis in 3 patients, and nonocclusive mesenteric ischemia (NOMI) in 2 patients. Exchange plasmapheresis was an effective treatment, with a response rate of 79%. A poor prognosis was evident when ARDS was present, with an overall survival rate of 46%.

CONCLUSION

Traditionally, TTP and HUS are considered the main entities of TM. It is evident that other manifestations of TM, if unrecognized in a timely fashion, can lead to fatality. The understanding of the pathophysiologic consequences of TM and the recognition of its atypical presentations are essential to achieve favorable outcomes in patients with this life-threatening disease.

Acute respiratory distress syndrome as a major clinical manifestation of thrombotic thrombocytopenic purpura

BACKGROUND

Although the classical triad of thrombocytopenia, microangiopathic hemolytic anemia, and neurological changes has been well recognized, thrombotic thrombocytopenic purpura (TTP) sometimes presents with atypical clinical features. Some cases of acute respiratory distress syndrome (ARDS) were suspected to be a manifestation of TTP.

METHODS

We examined retrospectively the medical records of patients with known TTP from 1981 to 1998. The patients who developed ARDS simultaneously with TTP were identified. Clinical, laboratory, and other pertinent data were reviewed; the clinical outcome was documented.

RESULTS

Seven out of 56 patients with an established diagnosis of TTP were identified as having ARDS. All 7 patients had progressive dyspnea, persistent hypoxemia with diffuse pulmonary infiltrates, and no evidence of localized pneumonia, pulmonary emboli, congestive heart failure, or other identifiable lung diseases. In addition to ARDS, 4 patients developed progressive neurological (mental) changes, 3 developed fever, and 2 developed renal failure. Six patients were treated with ventilatory support in the ICU. Upon establishing the diagnosis of TTP, 6 patients were treated with exchange plasmapheresis (EP) and 1 patient with an infusion of fresh frozen plasma. Within 2 days of initiation of EP, 4 patients showed marked respiratory improvement; shortly thereafter, mechanical ventilation was ended. Complete and long-lasting remission was achieved in all 4 patients. Three patients died because of delayed diagnosis and untimely employment of EP.

CONCLUSION

Life-threatening ARDS can be associated with TTP. It is recommended that all patients with ARDS and unexplained thrombocytopenia be evaluated for unrecognized TTP. Early recognition of ARDS associated with TTP and timely EP is critical to a favorable outcome.

Thrombotic thrombocytopenic purpura in acute pancreatitis

Thrombotic thrombocytopenic purpura (TTP) is a rare syndrome of unknown cause with an estimated incidence of one case per million. The disease is characterized by a pentad of symptoms: thrombocytopenia, microangiopathic hemolytic anemia, neurologic changes, renal dysfunction, and fever. It causes thrombosis in the microvasculature of several organs, producing diverse manifestations. Acute pancreatitis (AP) is a well-described consequence of TTP. We report a patient who developed TTP after presenting with AP, suggesting pancreatitis to be the cause, rather than a consequence, of TTP.

[Idiopathic thrombotic thrombocytopenic purpura or Moschowitz syndrome: current physiopathologic and therapeutic perspectives]

INTRODUCTION

The objective of this work was to review current data about the physiopathology, clinical features, and treatment of thrombotic thrombocytopenic purpura (Moschowitz's syndrome).

CURRENT KNOWLEDGE AND KEY POINTS

Thrombotic thrombocytopenic purpura is a rare disorder characterized by widespread thrombotic injuries of platelets in the microcirculation. Its physiopathology has been elucidated recently. Evidence of a deficiency of Von Willebrand's factor-cleaving protease would be due to either IgG antibodies in the acute form of the disease or constitutional deficiency in the chronic form of the disease.

FUTURE PROSPECTS AND PROJECTS

Plasma exchange is the current reference treatment. However, in the light of recent publications, either infusions of concentrates of purified enzyme or more intensive immunosuppressive therapy would be more specific.

Acute pancreatitis as a triggering factor for thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) constitutes a poorly understood multisystemic disease of vascular origin that may involve any organ by thrombotic occlusions of the small vessels. Treatment with plasmapheresis is the best therapeutic option at this present moment. Involvement of the pancreas is a well established feature of this disease, which has generally been interpreted as a consequence of pancreatic vascular compromise. However, there are a few cases in the literature in which the clinical signs of TTP developed well after the clinical and laboratory demonstration of acute pancreatitis (AP). Therefore, the possibility of pancreatic inflammation as a triggering factor of TTP may need to be considered. This cause-effect relationship between AP and TTP remains unclear. We report a patient with chronic pancreatitis presenting with two episodes of TTP, triggered by acute relapses of pancreatitis. TTP may, thus, constitute a hematological complication of AP. We discuss the pathophysiological aspects of this association, along with therapeutical options.

Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome secondary to pancreatitis

Pancreatitis is a rare (approximately 2.0%) complication of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). The opposite finding has rarely been reported. We present a case of an 18 years old obese male with alcohol associated pancreatitis (amylase 840 IU/L) who three days after onset, as the pancreatitis subsided (amylase 341 U/L), developed TTP/HUS. The TTP/HUS was marked by oliguria and severe renal failure (creatinine 1,326 mumol/L), was treated with daily plasma exchanges, obtained a complete response, and recovered renal function (creatinine 115 mumol/L). Similarly, in six of seven other cases from the medical literature the TTP/HUS occurred within 2-3 days of the onset of pancreatitis.

Thrombotic thrombocytopenic purpura causing sudden, unexpected death--a series of eight patients

Eight patients were presented to the medical examiner after dying suddenly and unexpectedly from thrombotic thrombocytopenic purpura. Compared with patients who die after prolonged hospitalization and treatment, these patients showed fewer neurologic symptoms and correspondingly fewer or no microthrombi within the brain. Only four of eight subjects developed fever, which further contributed to misdiagnosis. The differences in clinical presentation between our cases and most published series is striking and may be explained by shorter duration and no treatment. Each case contained the characteristic histology of thrombotic thrombocytopenic purpura. Ischemic injury to the heart and conduction system was the most likely mechanism of sudden death. Included in this series is a patient with acquired immunodeficiency syndrome (AIDS) diagnosed at autopsy, a concurrence that is now appearing more frequently in the medical literature.

Respiratory dysfunction in thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a rare disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurologic abnormalities, fever and renal dysfunction. in six of seven consecutive patients with thrombotic thrombocytopenic purpura seen in an eight month period, respiratory impairment was present. Respiratory dysfunction was characterized by tachypnea, hypoxemia nad infiltrates on chest roentgenogram. Five patients required mechanical ventilation. Two patients had cardiogenic pulmonary edema, but they remained hypoxemic despite treatment for pulmonary edema and maintenance of normal pulmonary capillary wedge pressure for more than 36 hours. Four patients died and autopsies revealed pulmonary edema, hemorrhage and hyaline thrombi. Pathologic examination of the heart also showed hyaline thrombi. Information from out patients with thrombotic thrombocytopenic purpura implicates respiratory dysfunction as a component of this disease as well as the classically described pentad. Cardiogenic and noncardiogenic pulmonary edema and possibly bleeding into the lung contributed to pulmonary impairment.

Thrombotic thrombocytopenic purpura--remission following splenectomy. Report of a case and review of the literature

A case of thrombotic thrombocytopenic purpura in which sustained remission followed splenectomy is described. Strong serologic evidence of concurrent infection with Mycoplasma pneumoniae was found in this case. Previously reported cases in which thrombotic thrombocytopenic purpura has been associated with infections are reviewed. An approach to management of this unusual and frequently fetal condition, is suggested, based on a detailed review of the recent literature.