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Xu J, Tan LN, Li LX, Qiao GY. Case report of thrombotic thrombocytopenic purpura during pregnancy with a review of the relevant research. Medicine (Baltimore) 2024; 103:e38112. [PMID: 38758904 PMCID: PMC11098172 DOI: 10.1097/md.0000000000038112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/12/2024] [Indexed: 05/19/2024] Open
Abstract
RATIONALE Thrombotic thrombocytopenic purpura (TTP) is a syndrome characterized by widespread blood vessel clotting and bleeding. It can affect individuals of any age but is more commonly observed in females, particularly during pregnancy. Pregnancy combined with TTP is a critical and rapidly progressing condition that is often misdiagnosed as an obstetric disorder like severe preeclampsia or HELLP syndrome. To deepen the understanding of TTP during pregnancy with the help of a clinical case. PATIENT CONCERNS A 20-year-old patient, is pregnancy 1 birth 0, 32 weeks dated by her last menstrual period, presented chest tightness, and shortness of breath after physical activity for 3 days. DIAGNOSES TTP. INTERVENTIONS At present, there are no preventive measures. Timely diagnosis and treatment are useful. Plasma exchange and treat to the patient hinder autoantibodies, such as gamma globulin, methylprednisolone, rituximab, and cyclosporine were effective. OUTCOMES The patient exhibited stable vital signs, normal examination results, and experienced no complications. We continued to monitor her progress after she was discharged. LESSONS SUBSECTIONS The acute onset of TTP is often associated with pregnancy, as it is a triggering factor. Timely identification, accurate diagnosis, and a comprehensive treatment approach involving plasma exchange, immunosuppressants, and the termination of pregnancy can lead to remission and a favorable outlook for the majority of patients.
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Affiliation(s)
- Jia Xu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Li-na Tan
- Department of Obstetrics and Gynecology, Xi’an People’s Hospital, Xi’an, China
| | - Ling-xia Li
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Gu-Yuan Qiao
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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Zhang X, Song X, Lv S, Li J, Jin Y, Jin J, Shao M, Zhu J, Chi C. Characteristics of patients with initial diagnosis of systemic lupus erythematosus in emergency department and their outcomes: a retrospective single-center study. Clin Rheumatol 2024; 43:667-676. [PMID: 38150055 DOI: 10.1007/s10067-023-06845-9] [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: 08/24/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023]
Abstract
STUDY OBJECTIVE This study aims to investigate the characteristics of patients with an initial diagnosis of systemic lupus erythematosus (SLE) in an emergency department (ED) and their outcomes. METHODS A total of 147 SLE patients (119 females and 28 males, mean age 26 ± 19 years) who visited the ED of the Peking University People's Hospital between January 2017 and June 2022 were enrolled in the study. Data on demographic information, clinical characteristics, comorbidities, therapy, and outcomes were collected. RESULTS Most patients visit ED because of symptoms related to SLE (74.8%, 110/147). The remaining 37 patients (25.2%) visited ED due to infection (43.2%, 16/37), gastrointestinal bleeding (10.8%, 4/37), coronary heart or cerebrovascular disease (18.9%, 7/37), macrophage activation syndrome or thrombotic microangiopathy (18.9%, 7/37), leukemia (5.4%, 2/37), and hepatic encephalopathy (2.7%, 1/37). Of the patients, 54.4% (80/147) were first diagnosed with SLE at the time of their ED visit. Thrombocytopenia events occurred significantly more frequently in this group of patients (OR 3.664, 95% CI 1.586-8.464, p = 0.002). Pulse steroid therapy was administered to 32.5% (26/80) of the patients with an initial diagnosis of SLE, and 26.3% (21/80) of these patients also received IVIG therapy during their ED visit. SLEDAI scores were significantly decreased after 6 months of therapy. The rate of mortality was 6.8% (10/147) in the 6-month follow-up period, and all the ten deaths happened in patients with disease-established SLE. The main causes of death were infections (two patients) and SLE flare (four patients). CONCLUSION Understanding disease patterns can contribute to physicians providing accurate diagnosis and efficient care for SLE patients in ED. Key Points • Systemic lupus erythematosus, a complex autoimmune disorder, can have either a chronic or a relapsing and remitting disease course. The disease can involve acute events or severe comorbidities, and frequent visits to the emergency department (ED) are inevitable. • It is essential to better understand which comorbidities can lead to emergency department visits. Accurate clinical diagnosis and appropriate interventions from ED physicians can have a strong impact on the prognosis of the disease. • Hematologic compromise attributed to SLE flare is the most common reason for ED visits. Owing to aggressive treatments, the clinical outcomes in patients with initial diagnosis of SLE have improved notably. • Our study highlights that early recognition and appropriate management of SLE-related conditions and other comorbidity in ED are crucial.
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Affiliation(s)
- Xiaoying Zhang
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xiaojing Song
- Department of Emergency, Peking University People's Hospital, 11 Xizhimen South St, Beijing, 100044, China
| | - Su Lv
- Department of Emergency, Peking University People's Hospital, 11 Xizhimen South St, Beijing, 100044, China
| | - Jia Li
- Department of Emergency, Peking University People's Hospital, 11 Xizhimen South St, Beijing, 100044, China
| | - Yuebo Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Jiayang Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Miao Shao
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, 11 Xizhimen South St, Beijing, 100044, China
| | - Cheng Chi
- Department of Emergency, Peking University People's Hospital, 11 Xizhimen South St, Beijing, 100044, China.
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Tsuda R, Kido T, Okada I, Kobiyama A, Kawataka M, Yamazaki M, Asano R, Hounoki H, Shinoda K, Tobe K. Thrombotic thrombocytopenic purpura that developed 3 years after systemic lupus erythematosus had remitted with rituximab therapy. Mod Rheumatol Case Rep 2023; 8:57-62. [PMID: 37341710 DOI: 10.1093/mrcr/rxad032] [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: 03/01/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/22/2023]
Abstract
Patients with systemic lupus erythematosus (SLE) occasionally develop thrombotic thrombocytopenic purpura (TTP), which can be fatal. Here, we report a case of TTP developing 3 years after SLE remitted with rituximab (RTX) therapy. A 50-year-old woman was treated with RTX for marked immune thrombocytopenic purpura and autoimmune haemolytic anaemia due to SLE relapse. After induction of remission, she was treated with prednisolone alone without maintenance therapy with RTX. Approximately 3 years later, she was readmitted with marked thrombocytopenia and severe renal dysfunction. On admission, she was diagnosed with TTP for the first time based on severe reduction in a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity and detection of ADAMTS13 inhibitors. CD19+ B cells in the patient's serum increased to 34%, suggesting that B cells had reactivated once the effect of RTX had subsided. The patient was successfully treated with plasmapheresis, glucocorticoid pulse therapy, and RTX. There are no previous reports of newly diagnosed TTP with ADAMTS13 inhibitor production after having achieved remission of SLE with RTX. Therefore, our report also discusses the potential mechanisms of production of new autoantibodies after B-cell depletion therapy.
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Affiliation(s)
- Reina Tsuda
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Toshiki Kido
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Ikuma Okada
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Aoi Kobiyama
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Masatoshi Kawataka
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Miho Yamazaki
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Ryoko Asano
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroyuki Hounoki
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Shinoda
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, University of Toyama, Toyama, Japan
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Lv M, Xu Q, Ye X, Yu Q. Sulperazon-induced acute reactive thrombocytopenia during treatment of systemic lupus erythematosus: a case report. Eur J Hosp Pharm 2023; 30:e18. [PMID: 34497130 PMCID: PMC10359788 DOI: 10.1136/ejhpharm-2021-002999] [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: 08/02/2021] [Accepted: 08/24/2021] [Indexed: 11/04/2022] Open
Abstract
The purpose of this study is to report a patient who developed acute reactive thrombocytopenia while undergoing treatment with sulperazon for systemic lupus erythematosus (SLE). Sulperazon is a broad-spectrum antibiotic that can act against a wide range of microorganisms, but rarely causes severe thrombocytopenic events. We describe a 62-year-old man with new-onset acute reactive thrombocytopenia who experienced a precipitous fall in the platelet count from 168×109/L to 1×109/L within 29 hours after exposure to sulperazon. Sulperazon was immediately discontinued followed by administration of intravenous immunoglobulin for six consecutive days. The platelet count eventually recovered and petechiae at the injection sites improved. No complications secondary to acute reactive thrombocytopenia were observed except petechiae.
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Affiliation(s)
- Mengen Lv
- Department of Laboratory Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, People's Republic of China
| | - Qing Xu
- Department of Laboratory Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, People's Republic of China
| | - Xianfei Ye
- Department of Laboratory Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, People's Republic of China
| | - Qian Yu
- Department of Laboratory Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, People's Republic of China
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5
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Mutoh T, Ohashi K, Nagai T, Sugiura A, Kudo M, Fujii H. Upfront rituximab therapy for thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case-based review. Rheumatol Int 2023; 43:373-381. [PMID: 35962219 DOI: 10.1007/s00296-022-05182-5] [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: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of various autoantibodies and deposition of immune complexes on tissues. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological disorder that rarely develops in SLE, mainly caused by inhibitory or clearing autoantibody against ADAMTS13. Although B cells play critical roles in the pathogenesis of two diseases, the role of B-cell depletion therapy using rituximab (RTX), a chimeric monoclonal antibody targeting CD20, in the management of TTP associated with SLE remains unclear. We present a 27-year-old woman who manifested TTP and nephritis simultaneously at diagnosis of SLE. This patient successfully responded to high-dose glucocorticoids combined with plasma exchange, and early administration of RTX-induced sustained remission of TTP without relapse over 16 months. This literature review in light of our case demonstrates relationship between early intervention with RTX and better treatment response despite the degree of ADAMTS13 activity. Moreover, we discuss the clinical features in TTP associated with SLE, risk factors for the development of TTP in SLE, and possible outcomes based on RTX dose. It is important to consider upfront RTX as a promising treatment strategy for SLE-associated secondary TTP to improve short-term response and long-term prognosis.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Keiichi Ohashi
- Department of Hematology, Ishinomaki Red Cross Hospital, Ishinomaki, Miyagi, Japan
| | - Taichi Nagai
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masataka Kudo
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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Suárez-Ale H, Fabian-Aquino E, Failoc-Rojas VE, Benites-Zapata VA, Ignacio-Cconchoy F. Case Report: Systemic lupus erythematous associated with thrombotic thrombocytopenic purpura, a diagnostic challenge. F1000Res 2022; 10:552. [PMID: 37457554 PMCID: PMC10338979 DOI: 10.12688/f1000research.51295.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 07/21/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon microangiopathic disease and sometimes is associated with systemic lupus erythematous (SLE). However, this probable causal relationship has not been completely proven. The diagnostic differentiation of both diseases is difficult in the first instance because they share similar characteristics that may overlap. We present a case of a 32-year-old woman with antecedents of epileptic seizures since she was 12 years old. The patient was admitted to the emergency room with a clinical picture of headaches, fever, paleness in the skin and mucosa, confused state, paresthesia, and transient spasticity of the extremities. The laboratory results revealed direct Coombs negative hemolytic anemia, severe thrombocytopenia, significant elevation of lactate dehydrogenase, and presence of schistocytes ++ in the peripheral film. In addition, positive antinuclear antibodies and positive anti-native DNA in titers of 1/320 and 1/160, respectively, were found. Urinalysis showed that serum creatinine was in normal range. Because of limited hospital resources, ADAMTS13 was not evaluated. However, based on clinical, hematological, and biochemical findings, we concluded that it was a case of TTP associated with SLE and indicated treatment with plasmapheresis and methylprednisolone pulses, obtaining a satisfactory response (normalization of biomarker levels, health condition) after the second session of plasmapheresis. Diagnosis of both SLE and TTP is often difficult to achieve; however, adequate correlation of clinical manifestations and laboratory tests, along with the help of partial therapeutic interventions, may lead to good clinical response.
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Affiliation(s)
- Horacio Suárez-Ale
- Internal Medicine Service, Hospital Nacional Alberto Saboga Sologuren, Lima, Peru
| | | | - Virgilio E. Failoc-Rojas
- Unidad de Investigación para la Generación y Sintesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Vicente A Benites-Zapata
- Unidad de Investigación para la Generación y Sintesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
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Lee CH, Huang YC, Li SS, Hsu YT, Chen YP, Chen TY. Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan. Front Med (Lausanne) 2022; 9:893273. [PMID: 35615090 PMCID: PMC9124890 DOI: 10.3389/fmed.2022.893273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6-7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0-4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.
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Affiliation(s)
- Chun-Hui Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ching Huang
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ting Hsu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsai-Yun Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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8
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Liang SJ, Zheng QY, Li MS, Lv MY, Chen WT, Yang Y. Response to belimumab in thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus: a case-based review. Clin Rheumatol 2022; 41:2561-2569. [PMID: 35524885 DOI: 10.1007/s10067-022-06155-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP), a life-threatening syndrome characterized by acute microangiopathic hemolytic anemia, thrombocytopenia, and visceral ischemia, can be classified as congenital TTP (inherited due to a mutation in ADAMTS13) and acquired TTP. The acquired TTP is further classified as idiopathic and secondary TTP. Systemic lupus erythematosus (SLE) is regarded as one of the most common causes of secondary TTP (SLE-TTP). In contrast to patients with idiopathic TTP, some patients with SLE-TTP, especially those diagnosed with refractory TTP, are resistant to plasma exchange and high-dose corticosteroids and usually require second-line drugs, including newly developed biologicals. Belimumab, a B-lymphocyte stimulator-specific inhibitor, was the first approved new therapy for SLE in the past 50 years. Only two cases of SLE-TTP using belimumab have been reported; however, detailed information has not been made available. Herein, we describe a 28-year-old female patient who presented with palm petechiae, strong tawny urine, and yellow stained skin and sclera, and was diagnosed with SLE-TTP supported by high anti-ANA titers; positive anti-SSA/SM; pleural effusion; decreased platelet count, hemoglobin, and complement C3/C4 counts; increased lactate dehydrogenase level, along with increased schistocytes; and a significant deficiency of ADAMTS13 activity. Belimumab (10 mg/kg) was administered after six plasma exchanges. Good efficiency and outcomes without any adverse events, SLE, or TTP relapse were observed during 12 months of follow-up. Therefore, belimumab is a promising choice for SLE-TTP management. In addition, we provide a focused review of the existing literature on the pathogenesis, diagnosis, and therapeutic strategies for SLE-TTP.
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Affiliation(s)
- Shen-Ju Liang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Quan-You Zheng
- Department of Nephrology and Urology, 958th Hospital, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400020, China
| | - Meng-Shan Li
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Ming-Ye Lv
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Wen-Ting Chen
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Yi Yang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China.
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Ge H, Shi Z, Zheng Z, Zhu Q, Hong L, Zhang Y, Shen J, Deng S. Coexistence of thrombotic thrombocytopenic purpura and immune thrombocytopenic purpura in an Asian woman: a case report. J Int Med Res 2022; 50:3000605221085127. [PMID: 35352601 PMCID: PMC8973045 DOI: 10.1177/03000605221085127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 33-year-old Chinese woman with a history of immune thrombocytopenic purpura presented with heavy menstrual bleeding. She was found to have thrombocytopenia, plasma ADAMTS13 activity of 0%, and positivity for the plasma ADAMTS13 inhibitor. She was diagnosed with the coexistence of thrombotic thrombocytopenic purpura and immune thrombocytopenic purpura. The patient was treated by plasmapheresis, a glucocorticoid, and rituximab. Her platelet level returned to normal, and she was discharged 28 days after admission. The number of plasmapheresis sessions and the timing of rituximab administration may be the key aspects of management of patients with thrombotic thrombocytopenic purpura who have underlying immune dysfunction caused by diseases such as immune thrombocytopenic purpura.
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Affiliation(s)
- Hangping Ge
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
| | - Zhan Shi
- Zhejiang Chinese Medical University, Bingwen Road, Hangzhou, China
| | - Zhiyin Zheng
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
| | - Qiuping Zhu
- Zhejiang Chinese Medical University, Bingwen Road, Hangzhou, China
| | - Lili Hong
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
| | - Yu Zhang
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
| | - Jianping Shen
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
| | - Shu Deng
- Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou, China
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10
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Jung JY, Kim JW, Suh CH, Kim HA. Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report. Medicine (Baltimore) 2022; 101:e28908. [PMID: 35363211 PMCID: PMC9282078 DOI: 10.1097/md.0000000000028908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology with diverse clinical and laboratory manifestations, including thrombocytopenia. About 25% of patients with SLE may be affected by thrombocytopenia, many of whom are asymptomatic. Some patients, however, experience platelet counts that drop quite low and predispose them to bleeding. Thrombotic thrombocytopenic purpura (TTP) is defined with a classic pentad of clinical features, such as thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms and signs, renal symptoms and signs, and fever. The association of TTP and SLE has been sporadically reported in the literature. PATIENT CONCERNS AND DIAGNOSIS We describe a 16-year-old girl with SLE and immune thrombocytopenia, in whom TTP was diagnosed. INTERVENTIONS AND OUTCOMES She was treated with pulse methylprednisolone, whose platelet counts normalized after therapy with plasmapheresis and an anti-CD20 monoclonal antibody (rituximab). CONCLUSION A pediatric patient with SLE and immune thrombocytopenia in whom TTP developed was treated with plasmapheresis and rituximab therapy successfully, though the patient experienced a disease relapsed after 18 months, which was controlled by the same management.
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MESH Headings
- Adolescent
- Anemia, Hemolytic/complications
- Child
- Female
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/therapy
- Plasmapheresis
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/complications
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/therapy
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Ji-Won Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
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11
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Anti-ADAMTS13 autoantibody profiling in patients with immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2021; 5:3427-3435. [PMID: 34495312 DOI: 10.1182/bloodadvances.2020004172] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/30/2021] [Indexed: 12/27/2022] Open
Abstract
Anti-A Disintegrin and Metalloproteinase with a ThromboSpondin type 1 motif, member 13 (ADAMTS13) autoantibodies cause a severe ADAMTS13 deficiency in immune-mediated thrombotic thrombocytopenic purpura (iTTP). ADAMTS13 consists of a metalloprotease (M), a disintegrin-like (D) domain, 8 thrombospondin type 1 repeats (T1-T8), a cysteine-rich (C), a spacer (S), and 2 CUB domains (CUB1-2). We recently developed a high-throughput epitope mapping assay based on small, nonoverlapping ADAMTS13 fragments (M, DT, CS, T2-T5, T6-T8, CUB1-2). With this assay, we performed a comprehensive epitope mapping using 131 acute-phase samples and for the first time a large group of remission samples (n = 50). Next, samples were stratified according to their immunoprofiles, a field that is largely unexplored in iTTP. Three dominant immunoprofiles were found in acute-phase samples: profile 1: only anti-CS autoantibodies (26.7%); profile 2: both anti-CS and anti-CUB1-2 autoantibodies (12.2%); and profile 3: anti-DT, anti-CS, anti-T2-T5, anti-T6-T8, and anti-CUB1-2 autoantibodies (8.4%). Interestingly, profile 1 was the only dominant immunoprofile in remission samples (52.0%). Clinical data were available for a relatively small number of patients with acute iTTP (>68), and no correlation was found between immunoprofiles and disease severity. Nevertheless, profile 1 was linked with younger and anti-T2-T5 autoantibodies with older age and the absence of anti-CUB1-2 autoantibodies with cerebral involvement. In conclusion, identifying acute phase and remission immunoprofiles in iTTP revealed that anti-CS autoantibodies seem to persist or reappear during remission providing further support for the clinical development of a targeted anti-CS autoantibody therapy. A large cohort study with acute iTTP samples will validate possible links between immunoprofiles or anti-domain autoantibodies and clinical data.
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12
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Orbe Jaramillo IA, De Lucas Collantes C, Martínez de Azagra A, Sebastián E. Systemic lupus erythematosus presenting as thrombotic thrombocytopaenic purpura in a child: a diagnostic challenge. BMJ Case Rep 2020; 13:13/9/e232002. [PMID: 32878846 DOI: 10.1136/bcr-2019-232002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thrombotic thrombocytopaenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterised by microangiopathic haemolytic anaemia, thrombocytopaenia and organ ischaemia. TTP is caused by a severe functional deficiency of ADAMTS13 activity. We describe a 10-year-old girl presenting anaemia and thrombocytopaenia with schistocytes. Urine protein to creatinine ratio was within nephrotic range. ADAMTS13 activity was 0%, and no anti-ADAMTS13 antibodies were found. A renal biopsy showed deposits of IgG, C3 and C1q in the capillary membrane, compatible with class V lupus nephritis. Therapeutic plasma exchange (TPE) was performed in conjunction with therapy consisting of steroids and mycophenolate mofetil. After 11 months of follow-up, the patient remains in remission with normal ADAMTS13 activity. Although acquired TTP is a rare finding in children, differential diagnosis of thrombotic microangiopathy should include ADAMTS13 and the assay should be performed early. TTP treatment is based on TPE, although the underlying disease must be ruled out to optimise treatment and prevent relapse.
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Affiliation(s)
| | | | | | - Elena Sebastián
- Onco-Hematology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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13
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Immune-mediated thrombotic thrombocytopenic purpura in patients with and without systemic lupus erythematosus: a retrospective study. Orphanet J Rare Dis 2020; 15:225. [PMID: 32859237 PMCID: PMC7456051 DOI: 10.1186/s13023-020-01510-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is associated with more deleterious outcomes in patients with systemic lupus erythematosus (SLE). However, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) levels and ADAMTS13 inhibitor were not routinely assayed in most previous studies. The objective of this study is to compare the characteristics and outcomes of immune-mediated TTP (iTTP) in patients with and without SLE. Methods The medical data of 28 patients with iTTP from Peking Union Medical College Hospital were analysed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients. Results All 28 patients had ADAMTS13 inhibitor and severe ADAMTS13 deficiency. iTTP was considered SLE-related (SLE-TTP) in 10 patients and primary (primary iTTP) in 18 patients. Renal involvement on presentation was more severe in patients with primary iTTP as determined by higher serum creatinine (162.7 ± 110.6 vs 73.3 ± 13.4 μmol/L, p < 0.01) and more prevalent acute kidney injury (72.2% vs 10.0%, p < 0.01) than in patients with SLE-TTP. More patients with SLE-TTP were treated with steroid pulse therapy (90.0% vs 16.7%, p < 0.01) and intravenous immunoglobulin (IVIG) (50.0% vs 5.6%, p = 0.01) compared to patients with primary iTTP. After adjustments for age and treatment, including steroid pulse therapy and IVIG treatment, the likelihood of clinical remission of SLE-TTP was significantly increased compared to that of primary iTTP (HR 7.6 [1.2, 50.1], p = 0.03). Mortality was also lower among patients with SLE-TTP than among patients with primary iTTP (0 vs 38.9%, p = 0.03). Conclusions Renal involvement was less severe in patients with SLE-TTP than in patients with primary iTTP. The treatment responses and outcomes of SLE-TTP were no worse and perhaps even better than those of primary iTTP. When TTP is diagnosed in SLE patients, the ADAMTS13 level and ADAMTS13 inhibitor profile should be considered in addition to clinical features.
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14
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Ma W, Bai W, Wu X, Zhao J, Li M, Zeng X. Successful treatment of refractory thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus with combination of plasma exchange and low-dose rituximab. Lupus 2020; 29:1961-1967. [PMID: 32838618 DOI: 10.1177/0961203320953473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenia purpura (TTP) associated with systemic lupus erythematous (SLE) (i.e., SLE-TTP) is a rare life-threatening disease often requiring intensive immunosuppressive agents, in addition to high-dose corticosteroids and plasma exchange (PEX). The optimal therapy of rituximab is unclear, but 375 mg/m2 weekly for 4 weeks is the usual practice, adopted from regimens for non-Hodgkin's lymphoma. We reported two cases of refractory SLE-TTP that showed good efficacy and prognosis with combination of methylprednisolone (MP) pulse, plasma exchange and low-dose rituximab (100 mg weekly for 4 weeks) treatment. METHODS Clinical data and treatment outcomes were reviewed of two patients diagnosed with refractory SLE-TTP at Peking Union Medical College Hospital between July 2017 and July 2018. RESULTS Both patients had SLE and presented with microangiopathic anemia and thrombocytopenia. Laboratory assays revealed high anti-nuclear antibody titers, reduced complement 3 and 4 levels, proteinuria, significantly elevated lactate dehydrogenase, schistocytes on peripheral blood smear, low ADAMTS13 activity, and the presence of ADAMTS13 inhibitor. In both patients, platelet counts remained below 50 × 109/L after MP pulse and 6 PEXs, confirming the diagnosis of refractory SLE-TTP. Low-dose rituximab (100 mg weekly for 4 weeks) was administered in both cases, resulting in normalization of platelet counts and significant reductions in B-lymphocyte counts. No TTP relapse or SLE flare occurred during 24 months of follow-up. CONCLUSIONS Our cases confirmed the efficacy and good follow-up outcomes of low-dose rituximab treatment (100 mg weekly for 4 weeks) for refractory SLE-TTP.
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Affiliation(s)
- Wanlu Ma
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xueyan Wu
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
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Caffarelli C, Santamaria F, Mirra V, Bacchini E, Santoro A, Bernasconi S, Corsello G. Advances in paediatrics in 2019: current practices and challenges in allergy, endocrinology, gastroenterology, public health, neonatology, nutrition, nephrology, neurology, respiratory diseases and rheumatic diseases. Ital J Pediatr 2020; 46:89. [PMID: 32600434 PMCID: PMC7325159 DOI: 10.1186/s13052-020-00853-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
We highlight the main developments that have been published during the first semester of the last year in the Italian Journal of Pediatrics. We have carefully chosen information from numerous exciting progresses issued in the Journal in the field of allergy, endocrinology, gastroenterology, neonatology, nutrition, nephrology, neurology, public health, respiratory diseases and rheumatic diseases. The impact on the care of patients has been placed in the broader context of studies that appeared in other journals. We think that many observations can be used directly to upgrade management of patients.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Parma, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Virginia Mirra
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ermanno Bacchini
- Unità Polispecialistica Pediatrica Centro Medi Saluser, Parma, Italy
| | - Angelica Santoro
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Parma, Italy
| | | | - Giovanni Corsello
- Department of Sciences for Health Promotion and Mother and Child Care “G. D’Alessandro”, University of Palermo, Palermo, Italy
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Systemic Lupus Erythematosus (SLE) with Acute Nephritis, Antineutrophil Cytoplasmic Antibody- (ANCA-) Associated Vasculitis, and Thrombotic Thrombocytopenic Purpura (TTP): A Rare Case Report with Literature Review. Case Rep Rheumatol 2020; 2019:8750306. [PMID: 31934484 PMCID: PMC6942753 DOI: 10.1155/2019/8750306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 11/17/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal disorder that requires urgent identification and treatment. The association of TTP with systemic lupus erythematosus (SLE) and vasculitis has been reported, however, never simultaneously. A 33-year-old woman with a history of SLE presented with acute abdominal pain, fever, arthralgias, and skin rash. She had acute severe hypertension, diffuse abdominal tenderness, and petechial rash. Diagnostic work-up revealed active urine sediment with proteinuria and hematuria and elevated creatinine, anemia, and thrombocytopenia. She was diagnosed with acute lupus nephritis and early microangiopathic hemolytic anemia in the setting of hypertensive urgency and started on intravenous methylprednisolone 500 mg once a day. Within 48 hours, she developed shock with multiorgan dysfunction and succumbed to her illness. Laboratory tests later showed ADAMTS13 activity less than 10% consistent with TTP and p-antineutrophil cytoplasmic antibody (ANCA) positivity. Autopsy revealed small-vessel vasculitis of the visceral organs. Kidney biopsy demonstrated diffuse proliferative glomerulonephritis. This case illustrates the occurrence of SLE nephritis, p-ANCA vasculitis, and severe TTP with rapidly fatal course, and the importance of having a low threshold for initiating plasma exchange therapy. Here, we discuss the case and provide a literature review on cases of TTP with SLE and vasculitis.
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17
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Furuya MY, Watanabe H, Sato S, Fujita Y, Tenmoku J, Matsuoka N, Asano T, Suzuki E, Kobayashi H, Migita K. An Autopsy Case of Mixed Connective Tissue Disease Complicated by Thrombotic Thrombocytopenic Purpura. Intern Med 2020; 59:1315-1321. [PMID: 32418955 PMCID: PMC7303452 DOI: 10.2169/internalmedicine.3939-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We herein report a patient with mixed connective tissue disease (MCTD) who had been stable for years but suddenly developed thrombotic thrombocytopenic purpura (TTP). The patient showed a clinical pentad of signs of TTP, low activity of ADAMTS13, and positivity of anti-ADAMTS13 antibodies. She did not respond to plasma exchange or steroid therapy and died five days after admission. An autopsy revealed microthrombi in the brain, heart, kidney, adrenal glands, esophageal submucosa, and bone marrow as well as diffuse alveolar hemorrhaging. Physicians should bear in mind that TTP can occur in MCTD patients regardless of disease activity.
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Affiliation(s)
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Jumpei Tenmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Eiji Suzuki
- Division of Rheumatology, Ohta-Nishinouchi Hospital, Japan
| | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
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18
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Choi M, Butler E, Clarke A, Girard LP, Gibson P, Skeith L. Managing pregnancy-associated clinical emergencies in systemic lupus erythematosus: a case-based approach. Expert Rev Clin Immunol 2019; 16:5-22. [PMID: 31791152 DOI: 10.1080/1744666x.2019.1699057] [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: 10/25/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE)-related thrombocytopenia during pregnancy and the postpartum period have been associated with adverse pregnancy outcomes and perinatal complications. In this case report, we present two SLE patients with thrombocytopenia emergencies secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and thrombotic thrombocytopenic purpura (TTP).Areas covered: The first case involved a 26-year-old woman, G1P0 at 26 weeks gestation (GA), with high-titer antiphospholipid antibodies (aPL) (positive lupus anticoagulant, anti-beta 2 glycoprotein-1 (aβ2GP1), anti-cardiolipin) and non-criteria aPL to phosphatidylserine/prothrombin complex and anti-domain 1 β2GP1. This case highlights the risks associated with aPL in pregnancy, considers management issues relating to anticoagulation during pregnancy and highlights the importance of maintaining a high index of suspicion for diagnosis of HELLP in SLE patients. The second case was a 36-year-old female, G3P2 at 32 weeks GA, with class III lupus nephritis (LN) who developed severe pre-eclampsia, which included mild thrombocytopenia. This case illustrates the challenges in identifying and differentiating between three pregnancy emergencies that can be seen in SLE patients (pre-eclampsia, LN, and TTP) and presents the management of TTP in peripartum SLE.Expert opinion: These two cases remind us of the importance of timely diagnosis and management of thrombocytopenia in this population.
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Affiliation(s)
- May Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin Butler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Louis Phillipe Girard
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Gibson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Hayashi N, Okada K, Tsuruyama Y, Kagaya Y, Kumano S, Ishikura Y, Takeda K, Nanbu M, Fujimoto K, Adachi H, Yokoyama H. Plasma exchange for thrombotic microangiopathy secondary to dermatomyositis associated with acute kidney injury and complement activation: a case report with literature review. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Thrombotic microangiopathy (TMA) in patients with connective tissue disease is rare but life-threatening. In particular, the survival rate of patients with dermatomyositis (DM) that develop TMA is low. The effectiveness of plasma exchange (PEX) therapy is unclear for the treatment of TMA secondary to DM.
Case presentation
We describe a case of a 28-year-old woman who developed severe DM complicated by aspiration pneumonia from dysphagia and acute kidney injury. The patient was unresponsive to corticosteroids and intravenous immunoglobulin (IVIG) therapy and developed TMA. In this case, immunofluorescence of skin biopsy revealed that complement activation was involved in the pathogenesis of DM. After 6 PEX therapies, thrombocytopenia improved. She was successfully treated by intensive care and PEX therapy.
Conclusions
PEX therapy was effective to treat TMA secondary to DM associated with complement activation.
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20
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Abstract
The color purple can be seen in several types of eruptions including inflammatory dermatoses like lichen planus, infectious dermatoses like ecthyma gangrenosum, neoplasms like Kaposi sarcoma, and vasculitis and vasculopathy. The current review focuses on the clinical appearance, pathophysiology, and treatment of several vasculitides and vasculopathies including capillaritis, cutaneous small-vessel vasculitis, immunoglobulin A (IgA) vasculitis, cryoglobulinemia, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, polyarteritis nodosum, warfarin-induced skin necrosis, heparin-induced thrombocytopenia, purpura fulminans, antiphospholipid antibody syndrome, calciphylaxis, levamisole-induced vasculopathy, and thrombotic thrombocytopenic purpura. Dermatologists play a central role in treating patients with cutaneous vasculitis and vasculopathy and may have the opportunity to facilitate identification of systemic disease by diagnosing cutaneous vasculitis and vasculopathy.
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Affiliation(s)
- Alexa B Steuer
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Jeffrey M Cohen
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA.
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21
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Sharma P, Gurung A, Dahal S. Connective Tissue Disorders in Patients With Thrombotic Thrombocytopenic Purpura: A Retrospective Analysis Using a National Database. J Clin Med Res 2019; 11:509-514. [PMID: 31236170 PMCID: PMC6575126 DOI: 10.14740/jocmr3850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022] Open
Abstract
Background Prior reports have shown acquired thrombotic thrombocytopenic purpura (TTP) co-existing with connective tissue disorders (CTD). However, these are mainly limited to case reports and case-series reports, and the patient characteristics and clinical outcomes in these patients are not well known. Methods We used National Inpatient Sample and Nationwide Inpatient Sample (NIS) database for the years 2009 to 2016 to identify all adult patients with TTP and searched for either the presence or absence of any co-existing CTD. These two cohorts of TTP patients were then compared using statistical methods for baseline patient characteristics and clinical outcomes. The primary outcome of interest was the all-cause in-hospital mortality and the secondary outcomes were in-hospital length of stay, in-hospital total charge and in-hospital complications. Results Of the 14,400 cases of TTP diagnosed between 2009 and 2016, nearly 9% (n = 1,247) had one or more underlying CTD. Patients with TTP were more likely to be young, black, female, with more than one comorbidity and with private insurance if they had an underlying CTD than when they did not have any underlying CTD. There was no difference in regards to the size, location or type of the hospital, or the time taken to initiate plasmapheresis. Patients being managed for TTP had a longer mean length of hospital stay and a greater mean total inpatient stay charge if they had underlying CTD. There was however no difference in the risks of inpatient mortality, acute coronary syndrome, cardiac arrest, acute stroke, need for mechanical ventilation or hemodialysis. Conclusion TTP and CTD frequently co-existed and contributed to a longer hospital stay and a greater hospital charge.
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Affiliation(s)
- Pratibha Sharma
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aveena Gurung
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Hospitalist Service, St. Joseph Hospital, Bangor, ME, USA
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22
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Li J, Jiang JJ, Wang CY, Jian S, Zhou Y, Ma MS, Tang XY, Wang L, Quan MY, Zhang Y, Xiao J, He YY, Song HM. Clinical features and prognosis of patients with thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus: a review of 25 cases. Ital J Pediatr 2019; 45:55. [PMID: 31036039 PMCID: PMC6489191 DOI: 10.1186/s13052-019-0641-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/29/2019] [Indexed: 02/06/2023] Open
Abstract
Objective To report the clinical features of patients with systemic lupus erythematosus (SLE) associated with thrombotic thrombocytopenic purpura (TTP). Their diagnosis, treatment, and prognosis were also discussed. Methods A total of 25 TTP-SLE pediatric patients were included in this study. Their clinical symptoms, laboratory findings, disease activity, and renal biopsy were retrospectively reviewed. Results The median age of the patient cohort was 14 years old. Nine patients were first diagnosed with SLE, followed by the diagnosis of TTP-SLE, whereas 15 patients were diagnosed with TTP and SLE concurrently. All the 25 TTP-SLE patients had decreased platelet count and microangiopathic hemolytic anemia. Fever, rash, edema and neurological symptoms were the main clinical symptoms. Fragmentation of erythrocytes on blood smear and increased LDH were found in all patients. Nineteen patients (76%) had impaired renal function. Renal biopsy showed that most of the patients had lupus nephritis class IV (20%) and TMA (20%). 13 patients (52%) were treated with glucocorticoids in combination with immunosuppressive agent, and 10 patients (40%) were treated with plasma exchange combined with glucocorticoids plus immunosuppressive agent. One patient died due to lung infection; others had disease remission. Fifteen patients had follow-up regularly, and their conditions were stable. Conclusion Patients with TTP-SLE often had moderate to severe lupus disease activity. Testing of LDH level and blood smear should be performed when kidney and neurological symptoms arise in children with SLE. The use of combination therapy, glucocorticoids plus immunosuppressive agent, provided satisfactory clinical outcome. Patients with refractory TTP-SLE will also need plasma exchange therapy.
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Affiliation(s)
- Ji Li
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jing-Jing Jiang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Chang-Yan Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Shan Jian
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yu Zhou
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ming-Sheng Ma
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiao-Yan Tang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lin Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mei-Ying Quan
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yu Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Juan Xiao
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yan-Yan He
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Hong-Mei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Amanat M, Thijs RD, Salehi M, Sander JW. Seizures as a clinical manifestation in somatic autoimmune disorders. Seizure 2019; 64:59-64. [DOI: 10.1016/j.seizure.2018.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/10/2018] [Accepted: 11/22/2018] [Indexed: 02/07/2023] Open
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24
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Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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Yue C, Su J, Gao R, Wen Y, Li C, Chen G, Zhang X, Li X. Characteristics and Outcomes of Patients with Systemic Lupus Erythematosus–associated Thrombotic Microangiopathy, and Their Acquired ADAMTS13 Inhibitor Profiles. J Rheumatol 2018; 45:1549-1556. [DOI: 10.3899/jrheum.170811] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 02/01/2023]
Abstract
Objective.To investigate the characteristics and outcomes of patients with systemic lupus erythematosus (SLE)–associated thrombotic microangiopathy (TMA) based on their ADAMTS13 inhibitor profiles.Methods.The medical data of 31 SLE patients with clinically diagnosed TMA were analyzed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients.Results.TMA was attributable to active SLE in 19 patients. ADAMTS13 inhibitor and severe ADAMTS13 deficiency were detected in 6 of them. Patients with ADAMTS13 inhibitor (n = 6) exhibited a lower platelet count (7.3 ± 5.1 vs 25.0 ± 17.8 × 109/l, p = 0.005) and more prevalent central nervous system (CNS) involvement (100.0% vs 23.1%, p = 0.003) than patients without ADAMTS13 inhibitor (n = 13). Patients with ADAMTS13 inhibitor also had mild renal involvement characterized by a higher estimated glomerular filtration rate (112.7 ± 18.0 vs 21.6 ± 12.0, p < 0.001), lower proteinuria level [0.6 (0.2–2.5) vs 8.1 (5.2–14.0) g/d, p = 0.011], and lower mean arterial pressure (95.3 ± 13.6 vs 117.5 ± 13.1 mmHg, p = 0.008) than was observed in patients without ADAMTS13 inhibitor. All patients with ADAMTS13 inhibitor achieved complete remission within 18.6 ± 8.7 days, while 3 patients (23.1%) without ADAMTS13 inhibitor achieved complete remission during a median followup of 5.0 months, even though more patients in this group received therapeutic apheresis (100.0% vs 50.0%, p = 0.021). The chance of complete remission increased by 10.8-fold (HR 10.8, 95% CI 1.8–65.5, p < 0.001) when ADAMTS13 inhibitor was present in SLE-associated TMA.Conclusion.Acquired ADAMTS13 deficiency is associated with more severe thrombocytopenia and CNS involvement, mild renal involvement, rapid resolution, and relatively good treatment response in SLE-associated TMA.
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Gordon C, Amissah-Arthur MB, Gayed M, Brown S, Bruce IN, D’Cruz D, Empson B, Griffiths B, Jayne D, Khamashta M, Lightstone L, Norton P, Norton Y, Schreiber K, Isenberg D. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology (Oxford) 2017; 57:e1-e45. [DOI: 10.1093/rheumatology/kex286] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Maame-Boatemaa Amissah-Arthur
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
| | - Mary Gayed
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Sue Brown
- Royal National Hospital for Rheumatic Diseases, Bath,
| | - Ian N. Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre,
- The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester,
| | - David D’Cruz
- Louise Coote Lupus Unit, Guy’s Hospital, London,
| | - Benjamin Empson
- Laurie Pike Health Centre, Modality Partnership, Birmingham,
| | | | - David Jayne
- Department of Medicine, University of Cambridge,
- Lupus and Vasculitis Unit, Addenbrooke’s Hospital, Cambridge,
| | - Munther Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital,
- Division of Women’s Health, King’s College London,
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London,
| | | | | | | | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
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Farkas P, Csuka D, Mikes B, Sinkovits G, Réti M, Németh E, Rácz K, Madách K, Gergely M, Demeter J, Prohászka Z. Complement activation, inflammation and relative ADAMTS13 deficiency in secondary thrombotic microangiopathies. Immunobiology 2017; 222:119-127. [DOI: 10.1016/j.imbio.2016.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/17/2016] [Accepted: 10/17/2016] [Indexed: 01/17/2023]
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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Mariotte E, Azoulay E, Galicier L, Rondeau E, Zouiti F, Boisseau P, Poullin P, de Maistre E, Provôt F, Delmas Y, Perez P, Benhamou Y, Stepanian A, Coppo P, Veyradier A. Epidemiology and pathophysiology of adulthood-onset thrombotic microangiopathy with severe ADAMTS13 deficiency (thrombotic thrombocytopenic purpura): a cross-sectional analysis of the French national registry for thrombotic microangiopathy. LANCET HAEMATOLOGY 2016; 3:e237-45. [DOI: 10.1016/s2352-3026(16)30018-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 01/05/2023]
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Roriz M, Landais M, Desprez J, Barbet C, Azoulay E, Galicier L, Wynckel A, Baudel JL, Provôt F, Pène F, Mira JP, Presne C, Poullin P, Delmas Y, Kanouni T, Seguin A, Mousson C, Servais A, Bordessoule D, Perez P, Chauveau D, Veyradier A, Halimi JM, Hamidou M, Coppo P. Risk Factors for Autoimmune Diseases Development After Thrombotic Thrombocytopenic Purpura. Medicine (Baltimore) 2015; 94:e1598. [PMID: 26496263 PMCID: PMC4620782 DOI: 10.1097/md.0000000000001598] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Autoimmune thrombotic thrombocytopenic purpura (TTP) can be associated with other autoimmune disorders, but their prevalence following autoimmune TTP remains unknown. To assess the prevalence of autoimmune disorders associated with TTP and to determine risk factors for and the time course of the development of an autoimmune disorder after a TTP episode, we performed a cross sectional study. Two-hundred sixty-one cases of autoimmune TTP were included in the French Reference Center registry between October, 2000 and May, 2009. Clinical and laboratory data available at time of TTP diagnosis were recovered. Each center was contacted to collect the more recent data and diagnosis criteria for autoimmunity. Fifty-six patients presented an autoimmune disorder in association with TTP, 9 years before TTP (median; min: 2 yr, max: 32 yr) (26 cases), at the time of TTP diagnosis (17 cases) or during follow-up (17 cases), up to 12 years after TTP diagnosis (mean, 22 mo). The most frequent autoimmune disorder reported was systemic lupus erythematosus (SLE) (26 cases) and Sjögren syndrome (8 cases). The presence of additional autoimmune disorders had no impact on outcomes of an acute TTP or the occurrence of relapse. Two factors evaluated at TTP diagnosis were significantly associated with the development of an autoimmune disorder during follow-up: the presence of antidouble stranded (ds)DNA antibodies (hazard ratio (HR): 4.98; 95% confidence interval (CI) [1.64-15.14]) and anti-SSA antibodies (HR: 9.98; 95% CI [3.59-27.76]). A follow-up across many years is necessary after an acute TTP, especially when anti-SSA or anti-dsDNA antibodies are present on TTP diagnosis, to detect autoimmune disorders early before immunologic events spread to prevent disabling complications.
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Affiliation(s)
- Mélanie Roriz
- From the Centre hospitalier universitaire Bretonneau, Service de néphrologie, Tours (MR, CB, J-MH, FTM); Centre hospitalier universitaire Hôtel-Dieu, Service de médecine interne A, Nantes (ML, MH); Centre hospitalier de Valenciennes, Service de néphrologie, Valenciennes (JD, YD); Centre de Référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, APHP (EA, LG, AW, J-LB, FP, FP, J-PM, CP, PP, TK, AS, DB, PP, DC, AV, J-MH, MH, PC, FTM, MH, PC); Université Paris Diderot, Sorbonne Paris Cité (EA, LG); Service de Réanimation Médicale, Hôpital Saint-Louis, AP-HP (EA); Service d'Immunologie Clinique, Hôpital Saint-Louis, AP-HP, Paris (LG); Service de Néphrologie, Hôpital Maison Blanche, Reims (AW); Sorbonne Université, UPMC Univ Paris 06 (J-LB); Service de Réanimation Médicale, CHU Saint-Antoine, AP-HP, Paris (J-LB); Service de Néphrologie, Hôpital Albert Calmette, Lille (FP); Service de Réanimation Polyvalente, Hôpital Cochin, AP-HP (FP, J-PM); Université Paris 5, Paris (FP, J-PM); Service de Néphrologie - Médecine Interne, Hôpital Sud, Amiens (CP); Service d'Hémaphérèse, Hôpital de Marseille Conception, Marseille (PP); Service de néphrologie-transplantation-dialyse, Hôpital Pellegrin, Bordeaux (YD); Unité d'Hémaphérèse thérapeutique, CHU de Montpellier (TK); Service de Réanimation Médicale, Centre Hospitalier Universitaire de Caen (AS); Service de Néphrologie, Dijon (CM); Service de Néphrologie, Hôpital Necker-Enfants Malades, AP-HP, Paris (AS); Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Dupuytren, Limoges (DB); Service de Réanimation, CHU Brabois, Nancy (PP); Service de néphrologie-immunologie clinique, hôpital Rangueil, Toulouse (DC); Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris (AV); Université Paris-Sud 11, Le Kremlin-Bicêtre (AV); Inserm U1009, Institut Gustave Roussy, Villejuif (PC); and Service d'Hématologie, Hôpital Saint-Antoine, AP-HP, Paris, France (PC)
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Delgado-García G, Cámara-Lemarroy C, Infante-Valenzuela A, Colunga-Pedraza P, Alarcón-Galván G, Armenta-González A, Villarreal-Velázquez HJ. Pure lupus podocytopathy first presenting as thrombotic thrombocytopenic purpura-like syndrome. Clin Rheumatol 2015; 35:2131-2136. [PMID: 26384822 DOI: 10.1007/s10067-015-3069-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 08/24/2015] [Accepted: 08/30/2015] [Indexed: 12/27/2022]
Abstract
Lupus podocytopathy (LP) is an uncommon proteinuric disorder in the spectrum of lupus nephropathy. Its histological features are similar to those described in minimal change disease (MCD) with or without mesangial immune deposits. Although infrequent, a close relationship between systemic lupus erythematosus (SLE) and thrombotic thrombocytopenic purpura (TTP) is well accepted. Proteinuria in the setting of SLE has previously been associated with the development of TTP-like syndrome. As far as we know, LP first presenting as a TTP-like syndrome has never been reported. Here, we describe the case of a previously healthy 45-year-old woman who developed simultaneously these two conditions and then we briefly review the literature on the topic, emphasizing the previous cases of concurrent initial diagnosis of both SLE and MCD (n = 7) and SLE and TTP (n = 72). In conclusion, renal biopsy is central to the management of SLE patients with nephrotic syndrome. Furthermore, in a SLE patient with anemia and thrombocytopenia, TTP should be part of the differential diagnosis, even when no schistocytes were detected in peripheral blood smear.
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Affiliation(s)
- Guillermo Delgado-García
- Department of Internal Medicine, University Hospital, Autonomous University of Nuevo León, Madero y Gonzalitos s/n, Col. Mitras Centro, C.P. 64460, Monterrey, Nuevo León, Mexico.
| | - Carlos Cámara-Lemarroy
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Adrián Infante-Valenzuela
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Perla Colunga-Pedraza
- Division of Hematology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Gabriela Alarcón-Galván
- Service of Anatomic Pathology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Arian Armenta-González
- Division of Rheumatology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
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Changcharoen B, Bolger DT. Thrombotic thrombocytopenic purpura as an initial presentation of systemic lupus erythematosus with acquired ADAMTS 13 antibody. BMJ Case Rep 2015; 2015:bcr-2014-208477. [PMID: 25701834 DOI: 10.1136/bcr-2014-208477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a female patient presenting with headache, fatigue, ecchymoses and recent, excessive vaginal bleeding. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia. Thrombotic thrombocytopenic purpura (TTP) was suspected. Plasma exchange and corticosteroids were started urgently. The patient responded favourably to the treatment. Subsequently, positive serological markers returned and were compatible with systemic lupus erythematosus (SLE). A disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13 (ADAMTS 13) activity was remarkably low with a positive inhibitory ADAMTS 13 antibody. Mycophenolate and hydroxychloroquine were started along with a prolonged course and taper of corticosteroids. These medications have been maintained with an excellent response in 14 months of follow-up.
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Affiliation(s)
- Bhisit Changcharoen
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Dennis Thomas Bolger
- Hospitalist Program, The Queen's Medical Center, Honolulu, Hawaii, USA Department of Medicine, University of Hawaii, Honolulu, Hawaii, USA
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Tang Y, Zhang X, Ji L, Mi X, Liu F, Yang L, Qin W. Clinicopathological and outcome analysis of adult lupus nephritis patients in China. Int Urol Nephrol 2015; 47:513-20. [PMID: 25563231 DOI: 10.1007/s11255-014-0903-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/20/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The objective of this study was to assess clinicopathological characteristics and outcomes of lupus nephritis adult patients in China. METHODS Clinicopathological features, treatment strategies, responses and outcome of 681 adult patients with biopsy-proved lupus nephritis were retrospectively analyzed. RESULTS Six hundred and eighty-one LN patients were included and followed up for 52.5 ± 14.1 months. Differences in age, disease duration, BP, proteinuria, serum albumin, creatinine, ANCA-positive ratio and SLEDAI scores were noticed between male and female patients, indicating severer disease in male patients. LN IV patients were much severer in systemic damage as well as immunological changes. During follow-up, 354 patients achieved CR, 107 patients achieved PR, 95 patients progressed to ESRD and 36 patients died. Prognosis and treatment response of patients with different histological types differ apparently. Renal outcome of patients with LN II and III was benign, while LN IV, V and VI was poor. Cyclophosphamide was effective in most patients. MMF and CNI could be used as salvage treatment. In multivariate analysis, BP, sCr, hypocomplementemia, severe proliferative lesion (LN IV or VI) and SLEDAI score were recognized as independent indicators of poor renal outcome. Infections, especially pulmonary fungus infection, thrombotic microangiopathy are the most common causes of death in LN patients. CONCLUSIONS Clinicopathological characteristics, treatment responses and long-term outcomes differ remarkably in LN patients with different gender and pathological subtypes. New indicators of poor renal outcome were identified. Infections and TTP were the most common causes of death in LN patients.
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Affiliation(s)
- Yi Tang
- Division of Nephrology, West China Hospital of Sichuan University, 37# Guoxue Rd, Chengdu, Sichuan, China
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Risk factors and clinical profile of thrombotic thrombocytopenic purpura in systemic lupus erythematosus patients. Is this a distinctive clinical entity in the thrombotic microangiopathy spectrum?: a case control study. Thromb Res 2014; 134:1020-7. [PMID: 25257921 DOI: 10.1016/j.thromres.2014.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The association of thrombotic thrombocytopenic purpura (TTP) with systemic lupus erythematosus (SLE) is rare. It is associated with high morbidity and mortality. Information about risk factors and clinical outcomes is scant. MATERIAL AND METHODS A retrospective case-control study was performed in a referral center in Mexico City between 1994 and 2013. Patients were diagnosed with TTP if they fulfilled the following criteria: microangiopathic haemolytic anaemia, thrombocytopenia, high LDH levels, normal fibrinogen and negative Coombs' test. Patients with SLE were diagnosed with ≥ 4 ACR criteria. We included three study groups: group A included patients with SLE-associated TTP (TTP/SLE; cases n = 22, TTP events n = 24); patients with non-autoimmune TTP (NA-TTP; cases n = 19, TTP events n = 22) were included in group B and patients with SLE without TTP (n = 48) in group C. RESULTS After multivariate analysis, lymphopenia < 1000/mm3 [OR 19.84, p = 0.037], high SLEDAI score three months prior to hospitalisation [OR 1.54, p = 0.028], Hg <7g/dL [OR 6.81, p = 0.026], low levels of indirect bilirubin [OR 0.51, p = 0.007], and less severe thrombocytopenia [OR 0.98, p = 0.009] were associated with TTP in SLE patients. Patients with TTP/SLE received increased cumulative steroid dose vs. NA-TTP (p = 0.006) and a higher number of immunosuppressive drugs (p = 0.015). Patients with TTP/SLE had higher survival than NA-TTP (p=0.033); however, patients hospitalised for TTP/SLE had a higher risk of death than lupus patients hospitalised for other causes CONCLUSIONS Lymphopenia is an independent risk factor for TTP/SLE. It is likely that patients with TTP/SLE present with less evident clinical features, so the level of suspicion must be higher to avoid delay in treatment.
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Lasek-Bal A, Kosarz-Lanczek K, Kazibutowska Z. Acute neurological symptoms of Moschcowitz disease - case report. Neurol Neurochir Pol 2014; 48:296-8. [PMID: 25168331 DOI: 10.1016/j.pjnns.2014.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 05/19/2014] [Accepted: 07/02/2014] [Indexed: 11/16/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP, Moschcowitz disease) is characterized by thrombotic microangiopathy leading to microvascular occlusion and ischemic dysfunction of various organs including the brain. In the course of the rare disease most patients develop neurological symptoms of varying severity and characteristics. The case presented is that of a 34-year-old female patient with profound thrombocytopenia, anemia and rapidly progressive neurological deterioration into coma with normal result of brain imaging. TTP was recognized on the basis of hematological analysis. The initiated steroid therapy and plasma exchange failed to prevent the turbulent course of disease in the patient, who died exhibiting symptoms of multiple organ failure caused by thrombotic microangiopathy. TTP remains to be a diagnostic challenge, particularly in the case of atypical symptoms or when neuroimaging and laboratory results are inconclusive. Before using the corticosteroids and plasma exchange, TTP had a case fatality rate of approx. 90% (Podolak-Dawidziak, 2013). Nowadays recovery is possible when vigorous treatment is introduced early in the course of this disease.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland.
| | - Katarzyna Kosarz-Lanczek
- Department of Neurology, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
| | - Zofia Kazibutowska
- Department of Neurology, Medical University of Silesia Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
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