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

Thrombotic microangiopathy associated with Mycoplasma pneumoniae infection

Thrombotic microangiopathy (TMA) comprises a process of sequential endothelial damage, microvascular thrombosis, consumptive thrombocytopenia and microangiopathic haemolytic anaemia that can affect several organs, including the kidney. A 36-year-old woman was presented with a petechial rash 3 weeks after an upper respiratory tract infection. Laboratory results showed normocytic normochromic anaemia, thrombocytopenia and evidence of TMA with decreased haptoglobin, elevated serum lactate dehydrogenase and a peripheral blood smear with numerous schistocytes. Treatment included daily plasmapheresis and prednisolone, with favourable clinical evolution. Antibodies anti-ADAMTS13 were positive, establishing the diagnosis of acquired thrombotic thrombocytopenic purpura. There was also serological evidence of a recent infection by Mycoplasma pneumoniae, and therefore the preceding respiratory tract infection by this agent was the most likely trigger for the disease. Due to the high mortality rate and poor outcomes, the prompt diagnostic and treatment are crucial in this rare disease. The identification of triggers related to this pathology can allow new therapeutic targets or preventive strategies.

Thrombotic Thrombocytopenic Purpura

Thrombotic thrombocytopenic purpura (TTP) is classically highlighted by a pentad of features: fever, hemolytic anemia, thrombocytopenia purpura, transient or permanent central nervous system signs, and renal disease. The antemortem diagnosis is reliant upon the multisystem clinical signs and symptoms in conjunction with severe hemolytic anemia and thrombocytopenia. Relapse is common within the first six months after initial presentation. Laboratory findings have been generally nonspecific per se, and antemortem tissue biopsy findings are frequently unrewarding. Recently, however, unusually large multimers of the Factor VIII:Ag molecule (von Willebrand protein) have been identified in the plasma of patients with TTP who have recovered from an acute attack. This observation is very important because it may lead to essential information on the nature of the inciting event in this devastating illness. The differential diagnosis includes several multisystem disease processes such as the hemolytic uremic syndrome, toxemia of pregnancy, systemic lupus erythematosus, subacute bacterial endocarditis, nonbacterial thrombotic endocarditis, immune thrombocytopenic purpura, and the postpartum renal failure syndrome. The hemolytic uremic syndrome, toxemia of pregnancy, and TTP may resemble each other, exhibit many overlapping features, and are probably related. The cause of TTP remains unknown; the overwhelming majority of cases occur in otherwise healthy people without any recognizable underlying illness. Since 1965 45 to 70% of patients survive, a significant improvement in contrast to the early 1900s when the mortality rate was greater than 90%. The most dramatic advance has been observed in therapeutics, namely the utilization of some mode of plasma therapy (either infusion alone or plasmapheresis followed by plasma infusion). Corticosteroids remain very important in the management of patients with TTP. Vincristine may be very helpful, but additional studies are needed. The efficacy of vinca alkaloids, chronic immunosuppressive therapy, and sple. nectomy remains undefined. At present there is very little, if any, evidence that antiplatelet agents, aspirin, and prostacyclin are beneficial to patients with TTP. Prompt diagnosis and vigorous aggressive therapy is critical for successful management of TTP patients.

Outcomes in the treatment of thrombotic thrombocytopenic purpura with splenectomy: a retrospective cohort study

The mainstay of treatment for thrombotic thrombocytopenic purpura (TTP) is plasma exchange (PE), but the role of splenectomy is still undefined. The records of all patients with TTP at a single center over a 20-year period were retrospectively reviewed. Response to plasma exchange was determined. The outcome of patients treated with splenectomy in the setting of TTP was evaluated. Sixty-one patients had been treated for TTP. Thirty-nine patients (64%) achieved complete remission (CR) with PE, nineteen (31%) of these achieving sustained CR and seventeen (28%) with relapsed TTP. Twenty patients (33%) had PE refractory TTP and two patients (3%) had PE dependent TTP. During this time period, 10 patients (16%) underwent splenectomy, four patients (7%) for PE dependent TTP, three (5%) for relapsed TTP, and three (5%) for refractory TTP. All of the patients achieved CR after splenectomy. Two patients who had undergone splenectomy had subsequent relapses, both with previously relapsed TTP. In relapsed patients the relapse rate after splenectomy was 0.27 events per patient year compared to 0.6 events per patient year before splenectomy. Median follow-up after splenectomy was 19 months (range 0.13-90 months). In conclusion, relapses in TTP can be managed successfully with additional PE or with splenectomy. PE dependent or refractory TTP can be successfully treated with splenectomy.

Treatment of plasma refractory thrombotic thrombocytopenic purpura with protein A immunoabsorption

The objective of this study was to assess the effect of protein A immunoabsorption in terms of response rate and toxicities in patients with classical thrombotic thrombocytopenic purpura (TTP) refractory to therapeutic plasma exchange. The study included nine females and one male with a diagnosis of classical TTP treated at multiple university hospital centers with protein A immunoabsorption (PAI) after having failed plasma exchange. The 10 patients had an age range 17-62 years. Prior to PAI, the patients had failed to respond to a mean of 15 (range 6-39) therapeutic plasma exchanges. Three patients had previous episodes of TTP. Evaluation for response to PAI included serial measurements of serum creatinine, lactate dehydrogenase (LDH), hemoglobin, hematocrit, and platelet count before, during, and up to 18 months post-PAI treatment. Seven of 10 study patients had resolution of their TTP. Six of the patients required six or fewer therapeutic PAIs and one required 12 treatments. All responding patients had evidence of improvement by the third PAI treatment. Three patients demonstrated no response to PAI, with two patients expiring from complications of TTP and one patient demonstrating a complete response to a subsequent therapy. No significant toxicity was noted with the use of PAI in this setting. Protein A immunoabsorption in patients with classical TTP refractory to plasma exchange can produce durable complete remissions and warrants comparative studies.

Fatal thrombocytopenia associated with Mycoplasma pneumoniae infection

The case of a 21-year-old male who presented with pneumonia associated with thrombocytopenia and bleeding and who died from intracranial haemorrhage is described. Very high titres of complement fixing and agglutinating anti-mycoplasma antibodies indicated recent Mycoplasma pneumoniae infection. Possible links between thrombocytopenia and M. pneumoniae infection are discussed.

Improved survival in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Clinical experience in 108 patients

BACKGROUND AND METHODS

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, central nervous system abnormalities, and renal dysfunction. In early reports the mortality approached 100 percent. A treatment protocol was introduced in 1979 for patients admitted to Johns Hopkins Hospital with the diagnosis of TTP-HUS. Treatment regimens included 200 mg of prednisone a day, for patients with minimal symptoms and no central nervous system symptoms, and prednisone plus plasma exchange, for patients with rapid clinical deterioration who did not improve after 48 hours of prednisone alone and for patients presenting with central nervous system symptoms and rapidly declining hematocrit values and platelet counts.

RESULTS

A total of 108 patients were treated, and 91 percent survived. Prednisone alone was judged to be effective in 30 patients with mild TTP-HUS (two relapses and two deaths). Plasma exchange plus prednisone was given to 78 patients with complicated TTP-HUS, resulting in 67 relapses and 8 deaths. Relapses occurred in 22 of 36 patients given maintenance plasma infusions. Neither splenectomy nor treatment with aspirin and dipyridamole was effective in those with a poor response to plasma exchange. None of the 71 patients tested had positive cultures for O157:H7 Escherichia coli. Nine percent of the patients were pregnant, and none gave birth to infants with TTP-HUS.

CONCLUSIONS

Effective treatment with 91 percent survival is available for patients with TTP-HUS.

The gingival biopsy in the diagnosis of thrombotic thrombocytopenic purpura

Gingival biopsy specimens from five patients with a clinical diagnosis of thrombotic thrombocytopenic purpura (TTP) were reviewed. All biopsy specimens demonstrated the characteristic histologic lesion associated with TTP. Review of the literature showed an average diagnostic yield of 37% (30/81) for this procedure. The increase in diagnostic correlation in this study may be explained in part by the marked degree of disease expression in the patients who underwent gingival biopsy. Three of the five patients who underwent gingival biopsies ultimately died of their disease. In addition, a persistent search through multiple serial sections for the characteristic lesion, beyond the usual three levels, was performed. Despite the disparity in diagnostic yield, we consider the gingival biopsy to be a safe diagnostic correlate of TTP because of easy access, rich vascularity, and low surgical morbidity. Furthermore, we recommend biopsy, as Goodman and colleagues have, only in areas of the gingiva that appear clinically normal and free of inflammation in order to reduce misinterpretation as a consequence of false-positive intraluminal fibrin thrombi that may occur with inflammation.

Management of treatment failures in thrombotic thrombocytopenic purpura

The prognosis and optimal management of patients with thrombotic thrombocytopenic purpura (TTP) who fail initial therapy with plasmapheresis or splenectomy are unclear. We report our experience with eight patients with TTP who did not respond to initial therapy. Seven patients achieved complete remission when alternate therapy was started soon after the recognition of initial treatment failure. One patient who received no alternative therapy died of progressive TTP. Our cases combined with those in the literature indicate a 74% salvage rate for patients who fail initial treatment for TTP. The combination of splenectomy, dextran, and steroids appears to be an effective treatment for patients with TTP who fail to respond adequately to plasmapheresis.

Rocky Mountain spotted fever presenting as thrombotic thrombocytopenic purpura

A patient presented with findings compatible with thrombotic thrombocytopenic purpura. The diagnosis of Rocky Mountain spotted fever was also considered because the patient was a hunter in a tick-infested area. He was treated for both diagnoses. The patient recovered and a diagnosis of Rocky Mountain spotted fever was confirmed by serologic methods. Clinical symptoms and hematologic parameters of severe Rocky Mountain spotted fever may resemble thrombotic thrombocytopenic purpura, implying that there may be similarities in the pathophysiology of both disorders.

Acute thrombotic thrombocytopenic purpura and cholecystitis

Acute thrombotic thrombocytopenic purpura (TTP) is a rare, usually fatal, disease characterized by widespread deposition of microvascular occlusive thrombi of platelets and fibrin. Although its exact etiology is unknown, numerous case reports in the medical literature have linked TTP with a variety of medical conditions, including systemic infections, vaccinations, pregnancy, and autoimmune diseases. A case of acute TTP occurring in a 28-year-old white male is presented and discussed, with emphasis on emergency department diagnosis and management. This patient's treatment included splenectomy. When laparotomy was performed for this procedure, the patient was found to have a distended, inflamed gallbladder, and a cholecystectomy was also performed. A review of the medical literature reveals this to be the first reported case of TTP occurring in association with cholecystitis.

Thrombotic thrombocytopenic purpura: clinical course and response to therapy in eight patients

The clinical manifestations, pathologic findings, and responses to therapy were reviewed in eight patients with thrombotic thrombocytopenia purpura (TTP). Only one exhibited all five cardinal manifestations; five showed a triad of anemia, thrombocytopenia, and neurologic abnormalities. Microangiopathic red cell changes on peripheral blood smear and severe thrombocytopenia were present in all. The serum LDH levels were initially elevated in all eight; this enzyme determination was extremely useful for following the course of the disease and its response to therapy. Pathologic evidence of TTP was most consistently found in lymph nodes, spleen, and bone marrow biopsies. All patients were treated with a combination of therapeutic modalities including plasma exchange with replacement by fresh frozen plasma. Using this approach, 7/8 entered a complete remission; however, disappearance of all clinical manifestations was not seen in two patients prior to splenectomy.

Inhibition of platelet-aggregating activity in thrombotic thrombocytopenic purpura plasma by normal adult immunoglobulin G

Plasma from patients with thrombotic thrombocytopenic purpura (TTP) caused the aggregation of autologous and homologous platelets, and effect which was inhibited by normal plasma. IgG purified from seven normal adults at a concentration of 0.7 mg/ml completely inhibited the platelet aggregation induced by plasma obtained from two TTP patients with active disease. The inhibition of platelet aggregation by human adult IgG was concentration dependent, and the inhibitory activity of human IgG was neutralized by rabbit antihuman IgG. Fab fragments inhibited the TTP plasma-induced platelet aggregation as well as intact IgG, whereas Fc fragments had no effect. Platelet aggregation caused by ADP, collagen, epinephrine, or thrombin was not affected by purified human IgG. The prior incubation of IgG with TTP plasma caused a significantly greater reduction of platelet aggregation by TTP plasma than that of IgG and platelet suspension, suggesting that the IgG inhibits TTP plasma-induced platelet aggregation through direct interaction with platelet aggregating factor in TTP plasma. IgG obtained initially from five infants and young children under the age of 4 yr did not possess any inhibitory activity. When one of the children reached 3 yr of age, his IgG inhibited the aggregation induced by one TTP plasma, but not that caused by another plasma. The IgG procured from the same boy at 4 yr of age inhibited the aggregation induced by both TTP plasmas. The IgG purified from the TTP plasma during active disease failed to inhibit the aggregation caused by the same plasma. After recovery, however, the IgG effectively inhibited aggregation. These observations suggest that platelet-aggregating factors present in the TTP plasma are heterogeneous in nature and that the IgG present in the normal adult plasma, which inhibits the TTP plasma-induced platelet aggregation, may be partially responsible for the success of plasma infusion therapy in TTP.

Treatment of thrombotic thrombocytopenic purpura. Evaluation of plasma exchange and review of the literature

This report examines the results of treatment in 21 patients with thrombotic thrombocytopenic purpura (TTP) diagnosed over a 4-year time period (1976-1980) with a review of the possible role of each form of therapy in relationship to the various proposed pathogenic mechanisms. There was a 76.2% (16/21) overall survival with no significant difference in initial hematologic values in patients not surviving. Patients not surviving did not achieve a sustained platelet count greater than 150,000/microliters at any time during their clinical course. 16 patients received steroids, antiplatelet agents and plasma exchange, with a total volume exchanged ranging from 20.8 to 1,455 ml/kg, as part of their treatment protocol. In this group of patients there was an 81.2% (13/16) survival, with 4 patients receiving additional therapy including splenectomy and/or vincristine. There was no correlation between the intensity of plasma exchange and the time to hematologic recovery. It is apparent that controlled clinical trials are necessary to better define the effectiveness of the present forms of therapy.

Microangiopathic hemolytic anemia, thrombocytopenia, and renal failure in patients treated for adenocarcinoma

Microangiopathic hemolytic anemia and thrombocytopenia secondary to disseminated intravascular coagulation is a well-described complication of widely metastatic carcinoma. The authors report four cases of gastric carcinoma, one case of colon cancer, and one case of adenocarcinoma of unknown primary in which the patient developed a syndrome analogous to thrombotic thrombocytopenic purpura, consisting of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure without definite evidence of disseminated intravascular coagulation. In contrast to previous reports, postmortem examination in three of the cases revealed no recurrence or only microscopic foci of residual tumor. In the remaining three, there was clinical and pathologic evidence of grossly disseminated carcinoma. Also in contrast to previous cases, all patients evidenced azotemia and proteinuria at the onset of the syndrome and ultimately uremia was a contributing cause of death. Coagulation profiles showed prolonged thrombin times and elevated fibrin degradation products in four instances and did not distinguish the patients with grossly metastatic disease from those with no tumor or only microscopic residua. Circulating immune complexes containing carcinoembryonic antigen were found in the patient with metastatic colon carcinoma. The syndrome was clinically identical whether or not grossly metastatic tumor was present, and it should not be attributed to advanced disease without definite clinical or pathologic evidence of a recurrence.

Thrombotic thrombocytopenic purpura (TTP) and splenectomy: a current appraisal

Thrombotic thrombocytopenic purpura (TTP) is a disease process characterized by microangiopathic anemia, fever, neurologic manifestations, renal abnormalities, and thrombocytopenia. These clinical findings are caused by vascular occlusions of the microcirculation. At present the utilization of splenectomy, in the treatment of this illness, remains a highly controversial subject. However, review of the literature reveals that 70% of the long term survivors of TTP had undergone splenectomy. This report presents five patients with TTP, four of whom had been splenectomized. Long term survival (greater than one year) was achieved in three individuals. It is recommended that splenectomy be considered as part of the initial management of all patients with TTP, in addition to high dose corticosteroids and antiplatelet drugs.

Respiratory dysfunction in thrombotic thrombocytopenic purpura

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