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Song Q, Wang Z. Association of Sjögren's syndrome with immune-mediated thrombotic thrombocytopenic purpura and posterior reversible encephalopathy syndrome: A case report. Heliyon 2024; 10:e36212. [PMID: 39224298 PMCID: PMC11367448 DOI: 10.1016/j.heliyon.2024.e36212] [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: 02/03/2024] [Revised: 06/19/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024] Open
Abstract
Background A patient with Sjögren's syndrome (SS), immune-mediated thrombotic thrombocytopenic purpura (ITTP), and posterior reversible encephalopathy syndrome (PRES) was reported, and all published cases with thrombotic thrombocytopenic purpura (TTP), PRES, and SS were retrieved and analysed. The patient's clinical data and treatment procedure have been discussed. Case summary A 45-year-old Chinese female was hospitalized with headache and low platelet count. She had previously presented to a local hospital with a 7-month history of epigastric discomfort and anorexia, and was diagnosed with SS and ITTP. Laboratory investigations after admission showed platelet (PLT) of 13*10^9/L, red blood cell (RBC) fragments of 6 %, ADAMTS13 Activity<0.2 %, anti-ADAMTS13 IgG of 88.3U/mL. Brain magnetic resonance imaging (MRI) showed gyriform restricted diffusion along with increased T2-FLAIR signal in the left frontal cortex and bilateral parietal temporal cortex. She was diagnosed with SS, ITTP and PRES, and received the treatment of methylprednisolone, cyclosporine, plasma exchange, IVIG, and rituximab. This patient did not experience the recurrence during the 8-month follow-up period. Conclusion ITTP and PRES are rare manifestations of SS. After a suspected or confirmed diagnosis of ITTP, plasma exchange and immunosuppressive therapy should be immediately administered. We suggest that rituximab could have additional therapeutic value for SS combined with ITTP and PRES.
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Affiliation(s)
- Qicheng Song
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Shandong, Jinan, PR China
| | - Zhankui Wang
- Department of Rheumatology and Clinical Immunology, Qianfoshan Hospital, Shandong, Jinan, PR China
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Luciano J, Gilardin L, Nocturne G, Bouzid R, Veyradier A, Mariette X, Coppo P, Bonnet I, Joly BS. Clinical, biological, prognostic characteristics of patients with immune-mediated thrombotic thrombocytopenic purpura and Sjögren's disease. RMD Open 2024; 10:e004426. [PMID: 39209728 PMCID: PMC11367322 DOI: 10.1136/rmdopen-2024-004426] [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: 04/14/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVES The association between immune-mediated thrombotic thrombocytopenic purpura (iTTP) and Sjögren disease (SjD) has been poorly investigated. This study presents the first retrospective cohort of iTTP-SjD aiming to identify risk factors for iTTP occurrence in SjD patients and examine their clinical course. METHODS Patients with iTTP-SjD were identified within the French TTP Registry based on American College of Rheumatology/European League Against Rheumatism 2016 criteria. A comparative analysis was conducted with two control groups comprising primary SjD (pSjD) patients from the French ASSESS cohort and idiopathic iTTP patients from the French TTP Registry. Demographic, clinical and biological data were retrospectively collected. RESULTS Thirty iTTP-SjD patients were included and compared with 65 pSjD and 45 idiopathic iTTP patients. The majority of iTTP-SjD patients (n=18) were diagnosed with SjD at the time of iTTP diagnosis. In comparison with the pSjD cohort, iTTP-SjD patients were diagnosed with SjD at a younger age (p=0.039) and showed a higher prevalence of anti-SjS-related antigen A antibody positivity and xerostomia (p=0.015, p=0.035, respectively). EULAR Sjogren's Syndrome Disease Activity Index showed similar activity levels between the two groups. iTTP-SjD patients were treated with plasma exchange (n=28), corticosteroids, rituximab (n=19) and caplacizumab (n=3). In comparison with the idiopathic iTTP cohort, mortality rates (log-rank tests, p=0.228), biological and clinical iTTP relapses (multivariate analysis, p=0.181) were comparable and short-term outcomes (survival at day 30, relapse) were favourable. CONCLUSION iTTP can be a rare complication in patients with SjD. Further studies involving larger cohorts and long-term follow-up are warranted to confirm these findings and to explore the efficacy of immunomodulators and caplacizumab in iTTP-SjD patients.
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Affiliation(s)
- Justine Luciano
- Inserm, CEA, Immunologie des maladies virales, auto-immunes, hématologiques et bactériennes (IMVA-HB/IDMIT/UMR1184), Université Paris-Saclay, Le Kremlin Bicêtre, France
- Département de Rhumatologie, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Laurent Gilardin
- Service de Médecine interne, Hôpital Jean Verdier, AP-HP. Hôpitaux Universitaires Paris Seine-Saint-Denis, Bondy, France
- INSERM UMRS-1138, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
- Centre National de Référence des Microangiopathies Thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
| | - Gaétane Nocturne
- Inserm, CEA, Immunologie des maladies virales, auto-immunes, hématologiques et bactériennes (IMVA-HB/IDMIT/UMR1184), Université Paris-Saclay, Le Kremlin Bicêtre, France
- Département de Rhumatologie, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Raïda Bouzid
- INSERM UMRS-1138, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
- Centre National de Référence des Microangiopathies Thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
| | - Agnès Veyradier
- INSERM UMRS-1138, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
- Centre National de Référence des Microangiopathies Thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP. Nord, Université Paris Cité, Paris, France
| | - Xavier Mariette
- Inserm, CEA, Immunologie des maladies virales, auto-immunes, hématologiques et bactériennes (IMVA-HB/IDMIT/UMR1184), Université Paris-Saclay, Le Kremlin Bicêtre, France
- Département de Rhumatologie, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Paul Coppo
- INSERM UMRS-1138, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
- Centre National de Référence des Microangiopathies Thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
- Service d'Hématologie, Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
| | - Isabelle Bonnet
- Département de Rhumatologie, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Université Paris Saclay, Le Kremlin Bicêtre, France
- Département de Rhumatologie, Hôpital Universitaire de Nîmes, Université de Nîmes, Nîmes, France
| | - Bérangère S Joly
- INSERM UMRS-1138, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
- Centre National de Référence des Microangiopathies Thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.6. Sorbonne Université, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP. Nord, Université Paris Cité, Paris, France
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Sudden Cardiac Death in a Patient with Thrombotic Thrombocytopenic Purpura: A Case Report. Hematol Rep 2022; 14:203-209. [PMID: 35735738 PMCID: PMC9222959 DOI: 10.3390/hematolrep14020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/11/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
A 49-year-old female was admitted to our hospital with malaise and gross hematuria. As ADAMTS13 (a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13) activity was absent and the ADAMTS13 inhibitor was detected, she was diagnosed with acquired thrombotic thrombocytopenic purpura (TTP). In addition to plasma exchange and corticosteroid therapy, she received rituximab therapy for inhibitor boosting but died suddenly of a cardiac arrest on day 9. The postmortem revealed microvascular platelet thrombi in multiple organs. In this case, the deterioration of the patient’s clinical status was considered to have been caused by inhibitor boosting-induced systemic microvascular occlusion. In particular, her sudden death may have been due to cardiovascular microthrombosis. Since inhibitor boosting can cause TTP patients to deteriorate rapidly, it is crucial to manage TTP patients who undergo inhibitor boosting appropriately. The monitoring of cardiac complications in TTP patients may also be essential, especially in the acute phase.
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Kasturiarachi BM, Alsbrook DL, Crook J, Shah N. An Immunologic Storm: A Case of Encephalitis and Thrombotic Thrombocytopenic Purpura With Underlying Likely Sjogren’s Syndrome Induced by a COVID-19 Immune Response. Neurohospitalist 2022; 12:529-535. [PMID: 35747766 PMCID: PMC8919096 DOI: 10.1177/19418744221079447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction There are rare cases of Sjogren’s syndrome presenting with manifestations of encephalitis. There are also rare patients with Sjogren’s presenting with acute thrombotic thrombocytopenic purpura (TTP). There are no cases of both occurring together as the only symptoms of the syndrome. During the COVID-19 pandemic, more cases of autoimmunity are being described given its robust immune response. It is important to keep a wide differential about these varying clinical presentations. Case Presentation Our patient is a 19-year-old female with a history of menorrhagia, recent COVID-19 infection, and remote suicidal ideation. She presented with headaches, vomiting, and psychosis. Her labs found platelets of 12,000 and she was soon discovered to have TTP. She was found to have contrast enhancing lesions scattered in her left hemisphere on magnetic resonance imaging as well as seizures. Her workup was negative for infection, but labs revealed a positive antinuclear antibody, elevated anti-Ro antibody (anti-SSA) and anti-La antibody (anti-SSB), and elevated COVID-19 antibodies. She was treated with antiepileptics, pulse dose steroids for 5 days, plasmapheresis, and weekly rituximab for 4 weeks. She had significant clinical improvement. Conclusion Sjogren’s syndrome can have varying presentations including TTP with or without encephalitis as a presenting feature. Autoimmunity can also be triggered from COVID-19 infection.
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Affiliation(s)
| | - Diana L. Alsbrook
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis TN, USA
| | - Jennifer Crook
- University of Tennessee Health Sciences Center College of Medicine, Memphis, TN, USA
| | - Namrata Shah
- Department of Pediatric Neurology, University of Tennessee Health Sciences Center, Memphis TN, USA
- Department of Pediatric Neurology, Methodist Le Bonheur Children’s Hospital, Memphis, TN, USA
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Zhang N, Ji C, Bao X, Yuan C. Early treatment of rituximab combined with eltrombopag for secondary thrombocytopenic purpura in rheumatoid arthritis: A case report. Medicine (Baltimore) 2022; 101:e28417. [PMID: 35029180 PMCID: PMC8757979 DOI: 10.1097/md.0000000000028417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Secondary immune thrombocytopenic purpura (ITP) is also known as acquired thrombocytopenic purpura, autoimmune disease is usually one of the important causes. There are few reports about treatment of refractory thrombocytopenic purpura in rheumatoid arthritis (RA). We report a case of refractory ITP in which changes in platelet-related markers with therapeutic agents are worthy of the attention of clinicians. PATIENT CONCERNS A 69-year-old woman admitted for ecchymosis on the neck and arms for 15 days presented to our hospital. She was diagnosed with RA 5 years ago. DIAGNOSIS The diagnosis met the American College of Rheumatology/European League Against Rheumatism 2010 classification criteria. The disease activity score 28 (DAS-28) was 4.6, indicating that the disease activity was moderate. INTERVENTIONS Treatment with first-line therapies and second-line treatment--eltrombopag (EPAG) were ineffective. Therefore, we performed rituximab combined with a low dose of EPAG. OUTCOMES The patient received 2 cycles of rituximab combined with EPAG, and reported no new petechiae on her buccal mucosa and limbs during follow-up. LESSONS This case suggests that early treatment of rituximab combined with EPAG is beneficial to patients with refractory ITP in RA. In terms of disease dynamic monitoring, immature platelet fraction (IPF) may be an auxiliary indicator for predicting efficacy, but its significance needs further study.
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Affiliation(s)
- Naidan Zhang
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
| | - Chaixia Ji
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
| | - Xiao Bao
- Department of Rheumatology, Peoples Hospital of Deyang City, Deyang, China
| | - Chengliang Yuan
- Department of Clinical Laboratory, Peoples Hospital of Deyang City, Deyang, China
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