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Pinheiro Maux Lessa M, Soares Ferreira Junior A, Graton M, Simon E, Ledbetter L, A Onwuemene O. De-novo immune-mediated thrombotic thrombocytopenic purpura following surgical and non-surgical procedures: A systematic review. Blood Rev 2024; 66:101197. [PMID: 38614840 DOI: 10.1016/j.blre.2024.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/15/2024] [Accepted: 04/05/2024] [Indexed: 04/15/2024]
Abstract
When de-novo immune-mediated thrombotic thrombocytopenic purpura (TTP) is diagnosed following an invasive procedure, clinical presentation patterns and outcomes are poorly defined. Therefore, in a systematic literature review of patients diagnosed with TTP following an invasive surgical or non-surgical procedure, we identified 19 studies reporting data on 25 patients. These data suggest that 1) TTP pathogenesis likely begins prior to the invasive procedure, 2) patients experience significant diagnostic delays, and 3) there is a high incidence of renal replacement therapy. Although invasive procedures may trigger TTP, further studies are needed to clarify the mechanisms underlying this association.
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Affiliation(s)
- Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | | | | | - Erin Simon
- Duke University Medical Center Library, Durham, NC, USA.
| | | | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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2
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Lim KH, Park J, Cho SH. Risk factors of trauma-induced thrombotic microangiopathy-like syndrome: A retrospective analysis. Medicine (Baltimore) 2022; 101:e29315. [PMID: 35866764 PMCID: PMC9302357 DOI: 10.1097/md.0000000000029315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Patients with trauma may develop thrombocytopenia. We encountered cases wherein patients experienced symptoms resembling thrombotic microangiopathies (TMAs) following severe trauma. As the condition of these patients did not meet the diagnostic criteria of thrombotic thrombocytopenic purpura and there was no mention of trauma among the several causes of TMAs, it was termed as "trauma-induced thrombotic microangiopathy-like syndrome" (t-TMAS). In this study, we aimed to analyze the risk factors that may affect the incidence of t-TMAS in patients with severe trauma. This retrospective study was conducted in the trauma intensive care unit at the Kyungpook National University Hospital between January 2018 and December 2019. The medical records of 1164 of the 1392 enrolled participants were analyzed. To assess the risk factors of t-TMAS, we analyzed age, sex, mechanism of trauma, abbreviated injury scale (AIS) score, injury severity score (ISS), hematological examination, and red blood cell volume transfused in 24 hours. Among the 1164 patients, 20 (1.7%) were diagnosed with t-TMAS. The univariate analysis revealed higher age, ISS, and myoglobin, lactate, creatine kinase-myocardial band (on admission), creatine phosphokinase, lactate dehydrogenase (LDH), and lactate (day 2) levels in the t-TMAS group than in the non-t-TMAS group. The red blood cell volume transfused in 24 hours was higher in the t-TMAS group than in the non-t-TMAS group. t-TMAS was more common in patients with injuries in the chest, abdomen, and pelvis (AIS score ≥3) than in those with head injuries (AIS score ≥3) alone. The higher the sum of AIS scores of the chest, abdomen, and pelvis injuries, the higher the incidence of t-TMAS. Multivariate analysis revealed age, ISS, and LDH level (day 2) to be independent predictors of t-TMAS. Trauma surgeons should consider the possibility of t-TMAS if thrombocytopenia persists without any evidence of bleeding, particularly among older patients with multiple severe torso injuries who have high LDH levels on day 2. Early diagnosis and treatment of t-TMAS could improve patients' prognosis.
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Affiliation(s)
- Kyoung Hoon Lim
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
- *Correspondence: Kyoung Hoon Lim, Department of Surgery, Kyungpook National University Hospital, 130, Dongduk-ro, Jung-gu, Daegu, 41944, South Korea (e-mail: )
| | - Jinyoung Park
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sung Hoon Cho
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
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3
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Häußler KS, Keese M, Weber CF, Geisen C, Miesbach W. Prospective Evaluation of the Pre-, Intra-, and Postoperative Kinetics of ADAMTS-13, von Willebrand Factor, and Interleukin-6 in Vascular Surgery. Clin Appl Thromb Hemost 2021; 26:1076029620930273. [PMID: 33023308 PMCID: PMC7545751 DOI: 10.1177/1076029620930273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative thrombotic thrombocytopenic purpura (TTP) shows clinical presentation similar to classical TTP, whereas exact pathophysiological contexts remain unexplained. In this study, we investigated intraoperative and postoperative changes in ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs, member 13), von Willebrand factor (VWF), large VWF multimers, and interleukin-6 (IL-6) in vascular surgery patients. The objective was to compare the impact of endovascular, peripheral, and aortic surgery on target parameters which are supposed to play a role in surgery-associated TTP. A total of 93 vascular surgery patients were included and divided into 4 groups according to the specific type of intervention they underwent. Blood samples were taken preoperatively, intraoperatively, and postoperatively on days 2 and 4. The ADAMTS-13 activity decreased significantly in 3 of the 4 groups during surgery (from median 81% to 49%, P < .001, in the group undergoing aortoiliacal interventions), whereas the percentage of large VWF multimers increased in all groups of patients. von Willebrand factor antigen increased significantly in all groups on postoperative day 2 and IL-6 increased significantly in the intraoperative and early postoperative period. There was no significant correlation between the intraoperative decrease in ADAMTS-13 and the increase in VWF or IL-6. No patient in this study showed clinical picture of TTP; the precise cause and clinical significance of moderately reduced ADAMTS-13 activity in the perioperative setting have not yet been definitely determined.
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Affiliation(s)
- Katja Susanne Häußler
- University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunohematology, Hemophilia Center, Frankfurt, Germany
| | - Michael Keese
- Department for Vascular Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Christian Friedrich Weber
- Department for Anesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Klinik Wandsbek, Hamburg, Germany
| | - Christof Geisen
- German Red Cross Blood Center Frankfurt am Main, Institute of Transfusion Medicine and Immunohematology, Frankfurt, Germany
| | - Wolfgang Miesbach
- University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunohematology, Hemophilia Center, Frankfurt, Germany
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Tordon B, Warkentin TE, Moore JC, Arnold DM. Post-cardiac surgery thrombotic thrombocytopenic purpura: presence of anti-ADAMTS13 autoantibodies at preoperative baseline. Platelets 2021; 33:479-483. [PMID: 33852372 DOI: 10.1080/09537104.2021.1912314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) rarely complicates acute inflammatory conditions such as surgery, including post-cardiac surgery. Review of 32 previously-reported cases of post-cardiac surgery TTP indicates that this disorder often occurs as early as 2-3 days following surgery, which seems too soon to implicate new formation of anti-ADAMTS13 autoantibodies as a consequence of surgery itself. We diagnosed post-cardiac surgery TTP in a 60-year-old female that began approximately 3 days post-coronary artery bypass surgery in which anti-ADAMTS13 autoantibodies were implicated. We therefore investigated whether anti-ADAMTS13 autoantibodies were also present in a preoperative blood sample. Inhibitory (neutralizing) anti-ADAMTS13 autoantibodies were detectable in the preoperative blood sample, suggesting that the role of surgery in precipitating TTP might be due to effects such as abrupt increase in postoperative von Willebrand factor levels and associated proinflammatory factors, rather than effects of surgery itself leading to the formation of de novo anti-ADAMTS13 autoantibodies.
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Affiliation(s)
- Bryan Tordon
- Department of Medicine, Division of Hematology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
| | - Jane C Moore
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
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Giordano G, Kyriazi E, Mavridis C, Persico F, Fragkoulis C, Gatto P, Georgiadis G, Giagourta I, Glykas I, Hurle R, Lazzeri M, Lughezzani G, Magnano San Lio V, Mamoulakis C, Meo D, Papadaki HA, Piaditis G, Pontikoglou C, Stathouros G. Oncology and complications. ACTA ACUST UNITED AC 2021; 93:71-76. [PMID: 33754613 DOI: 10.4081/aiua.2021.1.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 11/23/2022]
Abstract
This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of uretero-arterial fistula in a patient with long-term ureteral stenting for ureteral oncological stricture and a second case associated to retroperitoneal fibrosis were described. Abdominal CT, pyelography, cystoscopy were useful to show the origin of the bleeding. Angiography is useful for confirming the diagnosis and for subsequent positioning of an endovascular prosthesis which represents a safe approach with reduced post-procedural complications. Case 2: A case of patient who suffered from interstitial pneumonitis during a cycle of intravesical BCG instillations for urothelial cancer. The patient was hospitalized for more than two weeks in a COVID ward for a suspected of COVID-19 pneumonia, but he did not show any evidence of SARS-CoV-2 infection during his hospital stay. Case 3: A case of a young man with a functional urinary bladder paraganglioma who was successfully managed with complete removal of the tumor, leaving the urinary bladder intact. Case 4: A case of a 61 year old male suffering from muscle invasive bladder cancer who was admitted for a radical cystectomy and on the eighth postoperative day developed microangiopathic hemolytic anemia and thrombocytopenia, which clinically defines thrombotic microangiopathy.
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Affiliation(s)
- Giuseppe Giordano
- Unit of Diagnostic and Interventional Radiology, ARNAS "Garibaldi-Nesima", Catania.
| | - Evangelia Kyriazi
- Endocrinology Department, General Hospital of Athens "G. Gennimatas", Athens.
| | - Charalampos Mavridis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete.
| | - Francesco Persico
- Humanitas Clinical and Research Center - IRCCS, Department of Urology, Rozzano, Milan; University of Naples Federico II, Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Naples.
| | | | - Piergiorgio Gatto
- Ospedale di Sestri Levante - ASL 4 Liguria, Dipartimento Medico ad Elevata Integrazione Territoriale, Sestri Levante.
| | - George Georgiadis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete.
| | - Irene Giagourta
- Endocrinology Department, General Hospital of Athens "G. Gennimatas", Athens.
| | - Ioannis Glykas
- Urology Department, General Hospital of Athens "G. Gennimatas", Athens.
| | - Rodolfo Hurle
- Humanitas Clinical and Research Center - IRCCS, Department of Urology, Rozzano, Milan.
| | - Massimo Lazzeri
- Humanitas Clinical and Research Center - IRCCS, Department of Urology, Rozzano, Milan.
| | - Giovanni Lughezzani
- Humanitas Clinical and Research Center - IRCCS, Department of Urology, Rozzano, Milan; Humanitas University, Department of Biomedical Sciences, Rozzano, Milan.
| | | | - Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete.
| | - Diego Meo
- Unit of Diagnostic and Interventional Radiology, ARNAS "Garibaldi-Nesima", Catania.
| | - Helen A Papadaki
- Department of Hematology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete.
| | - George Piaditis
- Endocrinology Department, General Hospital of Athens "G. Gennimatas", Athens.
| | - Charalampos Pontikoglou
- Department of Hematology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete.
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Hossain MA, Ahmed N, Gupta V, Bajwa R, Alidoost M, Asif A, Vachharajani T. Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know? Chin J Traumatol 2021; 24:69-74. [PMID: 33518399 PMCID: PMC8071723 DOI: 10.1016/j.cjtee.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 12/10/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.
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Affiliation(s)
- Mohammad A. Hossain
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Nasim Ahmed
- Department of Surgery, Division of Trauma Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA,Corresponding author.
| | - Varsha Gupta
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Ravneet Bajwa
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Marjan Alidoost
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Arif Asif
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Tushar Vachharajani
- Global Nephrology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, 44103, USA
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Arapović A, Prgomet S, Saraga M, Kovačević T, Prohászka Z, Despot R, Marušić E, Radić J. Association of Appendicitis, Helicobacter Pylori Positive Gastritis and Thrombotic Thrombocytopenic Purpura in an Adolescent. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:131-133. [PMID: 30700693 PMCID: PMC6364441 DOI: 10.12659/ajcr.913129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) in children is a rare life-threatening syndrome, characterized by microangiopathic hemolytic anemia, thrombocytopenia with renal dysfunction, neurologic symptoms, and fever. TTP is usually caused by deficient activity of von Willebrand factor cleaving protease (ADAMTS13), due to either gene mutations or acquired via anti-ADAMTS13 autoantibodies. It can be triggered by bone marrow or solid organ transplantation, cardiothoracic-, abdominal-, and orthopedic surgeries, infections including very rarely Helicobacter pylori infection. CASE REPORT Here we report a case of a 16-year-old male with TTP, who presented with thrombocytopenia before an appendectomy. Seven days after surgery, our patient started to vomit, developed melena, and was admitted to our pediatric intensive care unit (PICU) with clinical presentation of shock. Gastroscopy revealed H. pylori positive hemorrhagic gastritis. The patient was treated by erythrocyte transfusions, fresh frozen plasma, human albumin, glucose-electrolyte solutions, vitamin K, platelet transfusion before implantation of central venous catheter, and antibiotics. After 36 hours, we started plasma exchange (PEX). Blood tests showed deficiency of ADAMTS13. Due to the presence of anti-ADAMTS13 autoantibodies, rituximab was administered. Due to generalized tonic-clonic seizures, he was artificially ventilated. Brain MR angiography showed small ischemic cerebro-vascular insult in the arteria cerebri media region. Despite immunosuppressive therapy and PEX, the patient did not improve completely until the H. pylori infection was eradicated. After which, he recovered completely. CONCLUSIONS We present a rare case of TTP accompanied with appendicitis and gastritis caused by H. pylori, where TTP improvement was dependent on H. pylori infection eradication.
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Affiliation(s)
- Adela Arapović
- Department of Pediatric, University Hospital in Split, Split, Croatia
| | - Sandra Prgomet
- Department of Pediatric, University Hospital in Split, Split, Croatia
| | - Marijan Saraga
- Department of Pediatric, University Hospital in Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Tanja Kovačević
- Department of Pediatric, University Hospital in Split, Split, Croatia
| | - Zoltán Prohászka
- 3 Department of Medicine, Research Laboratory, and HAS-SU Research Group of Immunology and Hematology, Semmelweis University, Budapest, Hungary
| | - Ranka Despot
- Department of Pediatric, University Hospital in Split, Split, Croatia
| | - Eugenija Marušić
- Department of Pediatric, University Hospital in Split, Split, Croatia
| | - Josipa Radić
- Department of Nephrology, University Hospital in Split, Split, Croatia
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Matsunaga Y, Ishimura M, Nagata H, Uike K, Kinjo T, Ochiai M, Yamamura K, Takada H, Tanoue Y, Hayakawa M, Matsumoto M, Hara T, Ohga S. Thrombotic microangiopathy in a very young infant with mitral valvuloplasty. Pediatr Neonatol 2018. [PMID: 29523490 DOI: 10.1016/j.pedneo.2018.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are microvascular occlusive disorders characterized by systemic or intrarenal platelet aggregation, thrombocytopenia, and red cell fragmentation. Post-operative TMA mostly occurs in adult patients with cardiovascular surgery, with the distinct pathophysiology from classical thrombotic thrombocytopenic purpura (TTP) although the exact pathophysiology remains unclear. CASE PRESENTATION A one-month-old infant developed TMA after the initial surgery of double outlet right ventricle. ADAM metallopeptidase with thrombospondin type 1 motif 13 (ADAMTS13) activity was sustained (64%) with the undetectable inhibitor. Von Willebrand factor (VWF) multimer analyses showed absent high-molecular weight multimers. Echocardiography disclosed severe mitral regurgitation. The mitral valve repair 32 days after the initial valvuloplasty led to prompt resolution of TMA. These suggested that TMA occurred in association with valvulopathy-triggered turbulent shear flow, mechanical hemolysis and endothelial damage. The consumption of large VWF multimers might account for the vascular high shear stress shown in Heyde syndrome. CONCLUSION The youngest case of post-operative TMA underscores the critical coagulopathy after the first surgical intervention for congenital heart disease.
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Affiliation(s)
- Yuka Matsunaga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Tadamune Kinjo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan; Department of Perinatal and Pediatric Medicine, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoshihisa Tanoue
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaki Hayakawa
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | | | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
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Ikegami K, Yamagishi T, Tajima J, Inoue Y, Kumagai K, Hirose Y, Kondo D, Nikkuni K. Post-traumatic thrombotic microangiopathy following pelvic fracture treated with transcatheter arterial embolization: a case report. J Med Case Rep 2018; 12:216. [PMID: 30089509 PMCID: PMC6083511 DOI: 10.1186/s13256-018-1757-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 06/28/2018] [Indexed: 12/21/2022] Open
Abstract
Background Thrombotic microangiopathy is caused by various conditions, but few cases secondary to trauma have been reported. We present the rare case of a patient with thrombotic microangiopathy-induced high-impact trauma with hemorrhagic shock. Case presentation An 86-year-old Japanese woman was transferred to our hospital after a traffic accident. A whole-body computed tomography scan revealed pelvic fractures with massive extravasation. She received a blood transfusion and emergency angiographic embolization. On post-traumatic day 1, she showed unexplained severe hemolysis, thrombocytopenia, and renal failure despite her stable condition. Disseminated intravascular coagulation was excluded because her activated partial thromboplastin time and prothrombin time-international normalized ratio were normal. Her fragmented red blood cell concentration was 28.8%. We suspected clinical thrombotic thrombocytopenic purpura and started plasma exchange. She recovered fully after the plasma exchange and was discharged on day 31. We eventually diagnosed thrombotic microangiopathy because her ADAMTS13 activity was not reduced. Conclusions It is important to recognize the possibility that thrombotic microangiopathy may occur after severe trauma. In the critical care setting, unexplained thrombocytopenia and hemolytic anemia should be investigated to eliminate the possibility of thrombotic microangiopathy. Early plasma exchange may help to prevent unfortunate outcomes in patients with thrombotic microangiopathy following trauma.
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Affiliation(s)
- Kaori Ikegami
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan.
| | - Takuma Yamagishi
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
| | - Junya Tajima
- The Department of Intensive Care Medicine, Yokohama City Minato Red Cross Hospital, 3-12-1 Shin-yamashita Naka-Ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Yukinori Inoue
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
| | - Ken Kumagai
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
| | - Yasuo Hirose
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
| | - Daisuke Kondo
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
| | - Koji Nikkuni
- The Department of Emergency and Critical Care Medicine, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata, 950-1197, Japan
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11
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Zhou Y, Reilly SD, Gangaraju R, Reddy VVB, Marques MB. An Unusual Presentation of Thrombotic Thrombocytopenic Purpura. Am J Med 2017; 130:e323-e326. [PMID: 28528921 DOI: 10.1016/j.amjmed.2017.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Yaolin Zhou
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City.
| | | | - Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Utah, Salt Lake City
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12
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Schott F, Gross AJ, Netsch C, Segerer S. [Thrombotic thrombocytopenic purpura after circumcision]. Urologe A 2016; 56:361-363. [PMID: 27272154 DOI: 10.1007/s00120-016-0147-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
After circumcision, a young man developed a wound healing disorder. After presenting to our hospital for further wound care, laboratory results showed acute renal failure with hemolytic anemia and thrombocytopenia, which led to the diagnosis of postoperative thrombotic thrombocytopenic purpura (TTP). After therapy with plasma exchange and immunosuppressive therapy with prednisolone and rituximab, the patient recovered with normalization of laboratory results. The TTP is associated with low activity of ADAMTS13 with microvascular platelet aggregation and hemolytic anemia.
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Affiliation(s)
- F Schott
- Abteilung für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Deutschland.
| | - A J Gross
- Abteilung für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Deutschland
| | - C Netsch
- Abteilung für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Deutschland
| | - S Segerer
- Abteilung für Nephrologie, Asklepios Klinik Barmbek, Hamburg, Deutschland
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13
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Yasuda S, Yamamoto M, Fukuda T, Ohtsuka Y, Miura O. Postoperative Atypical Hemolytic Uremic Syndrome Treated Successfully with Eculizumab. Intern Med 2016; 55:1171-5. [PMID: 27150874 DOI: 10.2169/internalmedicine.55.5955] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare type of HUS associated with dysregulation of the alternative complement pathway. We herein report the findings of a 43-year-old woman who developed aHUS two days after myomectomy. The serum C3 level was low and the sheep erythrocyte hemolytic assay showed a moderate hemolysis. The renal insufficiency progressed despite performing plasma exchange therapy, although a partial hematological response was observed. Thus, the patient was subsequently treated with the anti-C5 antibody eculizumab, which promptly improved and normalized the renal function. Although aHUS after surgery has rarely been reported, it needs to be promptly recognized and treated with eculizumab to prevent irreversible renal damage.
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Affiliation(s)
- Shunichiro Yasuda
- Department of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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