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Nanjiani D, Kumar S, Sharma N, Nasim S, Azim D, Parkash O. Congenital thrombotic thrombocytopenic purpura masquerading as vitamin B12 deficiency. Transfus Apher Sci 2023; 62:103728. [PMID: 37244785 DOI: 10.1016/j.transci.2023.103728] [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: 11/06/2022] [Revised: 04/20/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Congenital thrombotic thrombocytopenic purpura (CTTP), also called Upshaw-Schulman syndrome (USS), is a rare autosomal recessive disorder resulting from the deficiency of the ADAMTS13. CTTP is characterized by the formation of platelet-rich thrombi in small vessels of multiple organs, resulting in thrombocytopenia and microangiopathic hemolytic anemia, eventually leading to organ failure. CASE REPORT We present a case of an 11-month-old male infant with CTTP lacking classic features of the disease. Instead, his clinical picture portrayed vitamin B12 deficiency, leading to misdiagnosis and subsequent treatment delay. CONCLUSION This case led to the conclusion that congenital TTP should be suspected in case of vitamin B12 deficiency if the child does not respond to the vitamin B12 replacement therapy. We also emphasize that management for CTTP should be started at its earliest in case of increased clinical suspicion to avoid worse outcomes, especially in countries lacking rapid availability of enzyme assay.
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Affiliation(s)
- Deedar Nanjiani
- Dow Medical College, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Sohail Kumar
- Dow Medical College, Dow University of Health Sciences, Karachi 74200, Pakistan.
| | - Nitik Sharma
- Dow Medical College, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Sundus Nasim
- Dow Medical College, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Dua Azim
- Dow Medical College, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Oam Parkash
- Pediatric Department, Dr. Ruth K. M. Pfau Civil Hospital, Karachi 74200, Pakistan
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Cernichiaro-Espinosa M, Meizner-Grezemkovsky D, López-Santiago N, Borbolla-Pertierra AM, Morales-Cantón V, Cernichiaro-Espinosa LA. Bilateral Ischemic Retinopathy Associated With Upshaw-Schulman Syndrome: A Case Report. JOURNAL OF VITREORETINAL DISEASES 2022; 6:163-166. [PMID: 37008656 PMCID: PMC9976007 DOI: 10.1177/24741264211049694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: This is the first report to our knowledge of ischemic retinopathy in a pediatric patient with Upshaw-Schulman syndrome (USS). Methods: A 6-year-old girl previously diagnosed with USS was referred to our clinic with exodeviation of the left eye and a 2-month-long decrease in vision of both eyes. A dilated fundus examination showed a total vitreous hemorrhage in both eyes. The first course of action was conservative treatment, with the patient experiencing visual-acuity improvement in her right eye. Results: An ischemic retina and optic nerve atrophy was found once the left eye was cleared of the hemorrhage. Conclusions: We present a case of a vitreous hemorrhage, possibly secondary to an episode of severe thrombocytopenia. Following USS diagnosis, providers should perform dilated ophthalmologic examinations as part of initial and follow-up general evaluations. This case exemplifies that, in understudied and underdescribed pediatric retinal diseases, extreme therapeutic decisions—such as surgery—should not be rushed.
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Affiliation(s)
- Mariam Cernichiaro-Espinosa
- Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, I.A.P. Ciudad de México, Mexico
| | - Daniela Meizner-Grezemkovsky
- Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, I.A.P. Ciudad de México, Mexico
| | - Norma López-Santiago
- Pediatric Onco-Hemathology Department, Instituto Nacional de Pediatría, Ciudad de México, Mexico
| | | | - Virgilio Morales-Cantón
- Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, I.A.P. Ciudad de México, Mexico
| | - Linda A. Cernichiaro-Espinosa
- Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, I.A.P. Ciudad de México, Mexico
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Dykes KC, Kessler CM. First report of COVID-19 vaccine induced flare of compensated congenital thrombotic thrombocytopenic purpura. Blood Coagul Fibrinolysis 2022; 33:71-73. [PMID: 34693915 DOI: 10.1097/mbc.0000000000001097] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kaitlyn C Dykes
- Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, District of Columbia, USA
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A Case Report of Congenital Thrombotic Thrombocytopenic Purpura: The Peripheral Blood Smear Lights the Diagnosis. J Pediatr Hematol Oncol 2022; 44:e243-e245. [PMID: 33306605 DOI: 10.1097/mph.0000000000002032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022]
Abstract
We report on a 12-year-old boy with congenital thrombotic thrombocytopenic purpura, on who had an erroneous diagnosis as chronic immune thrombocytopenia. The patient presented with complaints of jaundice and skin rash. Laboratory analysis showed nonimmune hemolytic anemia and severe thrombocytopenia. Peripheral blood smear showed 8% schistocytes, polychromasia, and anisocytosis. The ADAMTS13 antigen and activity were suspected to be lower than 5% with any antibodies against the enzyme. The DNA sequence analyses resulted in compound heterozygosity consisting of c.291_391del in exon 3 and c.4143dupA in exon 29. Schistocyte (fragmented erythrocytes) on the peripheral blood smear is a light that illuminates the diagnosis. Early recognition of the disease can prevent inappropriate treatments and morbidities due to organ damage.
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Miodownik S, Pikovsky O, Erez O, Kezerle Y, Lavon O, Rabinovich A. Unfolding the pathophysiology of congenital thrombotic thrombocytopenic purpura in pregnancy: lessons from a cluster of familial cases. Am J Obstet Gynecol 2021; 225:177.e1-177.e15. [PMID: 33621545 DOI: 10.1016/j.ajog.2021.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 02/08/2021] [Accepted: 02/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP), a rare, potentially life-threatening thrombotic microangiopathy, manifests either as congenital TTP or acquired forms. It is caused by the absence or severe depletion of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13) protease, leading to the accumulation of ultra large von Willebrand factor multimers as well as extensive platelet adhesion and clumping, which can ultimately cause severe secondary end-organ damage. Pregnancy can provoke or exacerbate TTP, leading to maternal and fetal complications. OBJECTIVE In this report, we focused on pregnancy outcomes in a recently recognized cohort of congenital TTP patients of Bedouin Arab descent in southern Israel who were all homozygous for a novel c.3772delA variant of the ADAMTS13 gene, leading to the clinical manifestations of TTP largely during pregnancy. STUDY DESIGN All patients presented in this study belong to 2 closely related families of Arab Bedouin descent and were found to be homozygous for a novel ADAMTS13-c.3772delA variant. The cohort consisted of 19 females; 16 of them had congenital TTP and had been pregnant and were thus included. Patient data were collected from electronic medical records. RESULTS Of note, 13 women from our cohort, who delivered 14 fetuses (owing to 1 twin pregnancy), were diagnosed with congenital TTP following complicated pregnancies, which included recurrent pregnancy loss, stillbirth, early onset preeclampsia (both mild and severe), hemolysis, elevated liver enzymes and low platelet count syndrome, intrauterine growth restriction with abnormal Doppler flow, preterm premature rupture of membranes, and a total perinatal mortality rate of 30.7% (4/13). An additional 3 women, who were diagnosed owing to complications outside of pregnancy and at older ages, experienced TTP during their pregnancies, which occurred before diagnosis. Subsequent pregnancies were treated with fresh frozen plasma leading to a 100% fetal survival rate in the pregnancies that reached fetal viability. All placentas had lesions consistent with maternal vascular underperfusion. However, the severity and frequency of these lesions were lower in the 8 placentas from pregnancies treated with fresh frozen plasma. CONCLUSION This case series details a distinctive cohort of congenital TTP patients, all homozygous for the same, novel ADAMTS13 variant, who presented with clinical complications during pregnancy and maternal vascular lesions of underperfusion in the placenta. Our findings imply that the variant identified in the ADAMTS13 gene in our cohort may have a specific functional impact on the placenta, and that treatment with fresh frozen plasma during pregnancy ameliorates the course of the disease, leading to a milder phenotype or a normal pregnancy in the majority of cases.
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McFarlane PA, Bitzan M, Broome C, Baran D, Garland J, Girard LP, Grewal K, Lapeyraque AL, Patriquin CJ, Pavenski K, Licht C. Making the Correct Diagnosis in Thrombotic Microangiopathy: A Narrative Review. Can J Kidney Health Dis 2021; 8:20543581211008707. [PMID: 33996107 PMCID: PMC8072824 DOI: 10.1177/20543581211008707] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose of review: Thrombotic microangiopathy (TMA) is suspected in patients presenting with thrombocytopenia and evidence of a microangiopathic hemolytic anemia. Patients with TMA can be critically ill, so rapid and accurate identification of the underlying etiology is essential. Due to better insights into pathophysiology and causes of TMA, we can now categorize TMAs as thrombotic thrombocytopenic purpura, postinfectious (mainly Shiga toxin-producing Escherichia coli–induced) hemolytic uremic syndrome (HUS), TMA associated with a coexisting condition, or atypical HUS (aHUS). We recognized an unmet need in the medical community to guide the timely and accurate identification of TMA, the selection of tests to clarify its etiology, and the sequence of steps to initiate treatment. Sources of information: Key published studies relevant to the identification, classification, and treatment of TMAs in children or adults. These studies were obtained through literature searches conducted with PubMed or based on the prior knowledge of the authors. Methods: This review is the result of a consultation process that reflects the consensus of experts from Canada, the United States, and the United Arab Emirates. The members represent individuals who are clinicians, researchers, and teachers in pediatric and adult medicine from the fields of hematology, nephrology, and laboratory medicine. Authors, through an iterative review process identified and synthesized information from relevant published studies. Key findings: Thrombotic thrombocytopenic purpura occurs in the setting of insufficient activity of the von Willebrand factor protease known as ADAMTS13. Shiga toxin-producing Escherichia coli–induced hemolytic uremic syndrome, also known as “typical” HUS, is caused by gastrointestinal infections with bacteria that produce Shiga toxin (initially called verocytotoxin). A variety of clinical conditions or drug exposures can trigger TMA. Finally, aHUS occurs in the setting of inherited or acquired abnormalities in the alternative complement pathway leading to dysregulated complement activation, often following a triggering event such as an infection. It is possible to break the process of etiological diagnosis of TMA into 2 distinct steps. The first covers the initial presentation and diagnostic workup, including the processes of identifying the presence of TMA, appropriate initial tests and referrals, and empiric treatments when appropriate. The second step involves confirming the etiological diagnosis and moving to definitive treatment. For many forms of TMA, the ultimate response to therapies and the outcome of the patient depends on the rapid and accurate identification of the presence of TMA and then a standardized approach to seeking the etiological diagnosis. We present a structured approach to identifying the presence of TMA and steps to identifying the etiology including standardized lab panels. We emphasize the importance of early consultation with appropriate specialists in hematology and nephrology, as well as identification of whether the patient requires plasma exchange. Clinicians should consider appropriate empiric therapies while following the steps we have recommended toward definitive etiologic diagnosis and management of the TMA. Limitations: The evidence base for our recommendations consists of small clinical studies, case reports, and case series. They are generally not controlled or randomized and do not lend themselves to a stricter guideline-based methodology or a Grading of Recommendations Assessment, Development and Evaluation (GRADE)-based approach.
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Affiliation(s)
- Philip A McFarlane
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Martin Bitzan
- Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Kidney Centre of Excellence, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Catherine Broome
- Division of Hematology, Lombardi Cancer Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Dana Baran
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Hospital Centre, Montreal, QC, Canada
| | - Jocelyn Garland
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | | | - Kuljit Grewal
- Division of Hematology, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Anne-Laure Lapeyraque
- Division of Nephrology, Sainte-Justine Hospital Center, Montreal University, Montreal, QC, USA
| | - Christopher Jordan Patriquin
- Division of Medical Oncology & Hematology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
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Pikovsky O, Arafat M, Ovadia H, Sharoni Y, Al-Athamen K, Kanengisser-Pines B, Keren-Politansky A, Levi I, Erez O, Parvari R, Rabinovich A. Congenital thrombotic thrombocytopenic purpura in a large cohort of patients carrying a novel mutation in ADAMTS13 gene. Thromb Res 2020; 185:167-170. [DOI: 10.1016/j.thromres.2019.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/10/2019] [Accepted: 12/04/2019] [Indexed: 11/25/2022]
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Dai YL, Tang X, Chen HB, Peng QY, Guo X, Gao J. Hereditary Thrombotic Thrombocytopenic Purpura in a Chinese Boy With a Novel Compound Heterozygous Mutation of the ADAMTS13 Gene. Front Pediatr 2020; 8:554. [PMID: 33014938 PMCID: PMC7511713 DOI: 10.3389/fped.2020.00554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/30/2020] [Indexed: 01/10/2023] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (TTP) is caused by ADAMTS13 mutations with autosomal recessive inheritance. It typically presents during childhood and is frequently misdiagnosed as immune thrombocytopenia. We present a case of hereditary TTP with an undescribed compound heterozygous ADAMTS13 mutation in a Chinese boy. A 12-year-old boy with a history of intermittent thrombocytopenia in the prior 6 years had severe deficiency of plasma ADAMTS13 and harbored a novel compound heterozygous mutation which was also identified in his sister. The c.577C>T was a pathogenic variant reported exclusively in Japanese cases. The undescribed c.2397C>A non-sense mutation was predicted to encode a truncated protein. Identification of the specific novel heterozygous ADAMTS13 mutation in the Chinese family, consisting a variant restricted to Asian individuals and an undescribed c.2397C>A non-sense mutation, demonstrates genetic diversity underlying hereditary TTP, and possibly ethnic skewed mutation profiles.
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Affiliation(s)
- Yi-Ling Dai
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Xue Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Hong-Bo Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Qiu-Yu Peng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Xia Guo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Ju Gao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
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Tenison E, Asif A, Sheridan M. Congenital thrombotic thrombocytopenic purpura presenting in adulthood with recurrent cerebrovascular events. BMJ Case Rep 2019; 12:12/10/e229481. [PMID: 31585956 DOI: 10.1136/bcr-2019-229481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is a rare, life-threatening disease, characterised by episodes of microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and small vessel thrombosis. We describe a case of cTTP first diagnosed at age 70 years in a female presenting with an acute ischaemic stroke and thrombocytopenia, in whom A Disintegrin And Metalloproteinase with a Thrombospondin type 1 Motif, member 13 (ADAMTS13) levels were <10%, suggestive of thrombotic thrombocytopaenic purpura (TTP). The patient underwent plasma exchange and started rituximab for presumed immune TTP; however, anti-ADAMTS13 antibody titres were negative on two occasions. This, together with a history of pregnancies complicated by presumed disseminated intravascular coagulation, and two previous episodes of sepsis with MAHA, prompted investigation for cTTP, which was confirmed by genetic testing. Despite treatment with infusions of solvent/detergent-treated, virus-inactivated fresh frozen plasma, she has re-presented with further neurological deficit, associated with new infarcts on imaging. cTTP has a varied phenotype which, as demonstrated in this case, can include large vessel occlusion.
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Affiliation(s)
- Emma Tenison
- Translational Health Sciences, University of Bristol Musculoskeletal Research Unit, Bristol, UK.,Older People's Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Ashar Asif
- Medical School, University of Bristol, Bristol, UK
| | - Mathew Sheridan
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Beauvais D, Venditti L, Chassin O, Joly B, Ameri A, Boisseau P, Lambotte O, Coppo P, Veyradier A, Denier C. Inherited Thrombotic Thrombocytopenic Purpura Revealed by Recurrent Strokes in a Male Adult: Case Report and Literature Review. J Stroke Cerebrovasc Dis 2019; 28:1537-1539. [PMID: 30930238 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/24/2019] [Accepted: 03/02/2019] [Indexed: 12/16/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy related to a severe deficiency of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13). In this article, we describe the first case of a young male adult suffering from a hereditary TTP revealed by recurrent strokes, relapsing despite antiplatelet and anticoagulant therapy. Because of the persistent moderate thrombocytopenia, plasmatic ADAMTS13 activity was investigated and was found lower than 5% in the absence of anti-ADAMTS13 IgG. Direct sequencing of ADAMTS13 gene led to the diagnosis of Upschaw-Schulman syndrome (USS). Inherited TTP or USS is a rare autosomal recessive inherited disease leading to a severe deficiency of ADAMTS13 mostly beginning in childhood or in young female adult during pregnancy. Our patient was treated with fresh frozen plasma every 2 weeks. One year after diagnosis, he was free of neurological symptoms. Around 12 cases of inherited TTP diagnosed in adults (outside pregnancy) are described in literature. Only 4 of them exhibited a stroke. This case is the first late onset genetic TTP revealed by recurrent strokes, moderate thrombocytopenia without anemia.
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Affiliation(s)
- Diane Beauvais
- Department of Neurology, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Laura Venditti
- Department of Neurology, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France.
| | - Olivier Chassin
- Department of Neurology, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Bérangère Joly
- Haematology biology department, Lariboisière Hospital, AP-HP and EA3518, University Paris Diderot, Paris, France
| | - Alain Ameri
- Neurology, Meaux Hospital, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Pierre Boisseau
- Haematology biology department, Lariboisière Hospital, AP-HP and EA3518, University Paris Diderot, Paris, France
| | - Olivier Lambotte
- Internal medicine, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Paul Coppo
- Haematology department, Saint Antoine Hospital, AP-HP, University Pierre et Marie Curie, Paris, France
| | - Agnès Veyradier
- Haematology biology department, Lariboisière Hospital, AP-HP and EA3518, University Paris Diderot, Paris, France
| | - Christian Denier
- Department of Neurology, Bicêtre Hospital, AP-HP, University Paris Sud Saclay, Le Kremlin-Bicêtre, France
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Bommer M, Wölfle-Guter M, Bohl S, Kuchenbauer F. The Differential Diagnosis and Treatment of Thrombotic Microangiopathies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:327-334. [PMID: 29875054 PMCID: PMC5997890 DOI: 10.3238/arztebl.2018.0327] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 09/04/2017] [Accepted: 02/14/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombotic microangiopathies are rare, life-threatening diseaseswhose care involves physicians from multiple specialties. The past five years haveseen major advances in our understanding of the pathophysiology, classification,and treatment of these conditions. Their timely diagnosis and prompt treatment cansave lives. METHODS This review is based on pertinent articles published up to 17 December2017 that were retrieved by a selective search of the National Library of Medicine'sPubMed database employing the terms "thrombotic microangiopathy," "thromboticthrombocytopenic purpura," "hemolytic-uremic syndrome," "drug-induced TMA," and"EHEC-HUS." RESULTS The classic types of thrombotic microangiopathy are thrombotic thrombo -cytopenic purpura (TTP) and typical hemolytic-uremic syndrome (HUS), also knownas enterohemorrhagic Escherichia coli-associated HUS (EHEC-HUS). There are anumber of further types from which these must be differentiated. The key test,beyond a basic hematological evaluation including a peripheral blood smear, ismeasurement of the blood level of the protease that splits von Willebrand factor,which is designated ADAMTS13 (a disintegrin and metalloprotease with thrombo -spondin type 1 motif, member 13). The quantitative determination of ADAMTS13, ofADAMTS13 activity, and of the ADAMTS13 inhibitor serves to differentiate TTP fromother types of thrombotic microangiopathy. As TTP requires urgent treatment,plasmapheresis should be begun as soon as TTP is suspected on the basis of afinding of hemolysis with schistocytes and thrombocytopenia. The treatment shouldbe altered as indicated once the laboratory findings become available. CONCLUSION Rapid differential diagnosis is needed in order to determine the specifictype of thrombotic microangiopathy that is present, because only patients with TTPand only a very small percentage of those with atypical hemolytic-uremic syndrome(aHUS) can benefit from plasmapheresis. The establishment of a nationwideregistry in Germany with an attached biobank might help reveal yet unknowngenetic predispositions.
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Affiliation(s)
- Martin Bommer
- Department of Hematology, Oncology, Palliative Care and Infectious Diseases, Alb-Fils-Kliniken, Göppingen, Germany; Department of Internal Medicine III, Ulm University, Ulm, Germany
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Upshaw-Schulman Syndrome: Novel homozygous missense mutation. Thromb Res 2017; 158:83-85. [PMID: 28858683 DOI: 10.1016/j.thromres.2017.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 11/23/2022]
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ADAMTS13 missense variants associated with defective activity and secretion of ADAMTS13 in a patient with non-cirrhotic portal hypertension. Indian J Gastroenterol 2017; 36:380-389. [PMID: 28980147 DOI: 10.1007/s12664-017-0786-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Non-cirrhotic intrahepatic portal hypertension (NCIPH) is characterized by thrombotic microangiopathy of the portal venous system, low ADAMTS13 (a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs-13), and high vWF (von Willebrand factor) levels. This study aimed to screen for ADAMTS13 mutations, focusing on the CUB domain, in these patients. METHODS Prospectively recruited NCIPH patients and healthy volunteers underwent tests for plasma vWF-ADAMTS13 balance. Sanger sequencing of the CUB domain of ADAMTS13 was done in a subset of the NCIPH patients, and the detected mutation was screened for in all the study participants. Next-generation sequencing of clinically relevant exome and liver immunostaining for ADAMTS13 was done in patients with detected ADAMTS13 mutation. RESULTS Plasma vWF-ADAMTS13 balance was significantly altered in 24 NCIPH patients (Child's class A:23, B:1) as compared to 22 controls. On initial sequencing of the CUB domain (17 cases and 3 controls), one NCIPH patient showed a rare missense variant (SNV) at position c.3829C >T resulting in p.R1277W (rs14045669). Subsequent RFLP analysis targeted to the R1277W variant did not detect this in any other NCIPH patient, nor in any of the 22 controls. The NCIPH patient with the R1277W variant had severe ADAMTS13 deficiency, consistently high vWF, other missense SNVs in ADAMTS13, vWF, and complement genes. Immunostaining of his liver biopsy revealed globules of ADAMTS13 within stellate cells. CONCLUSIONS We report missense variants in ADAMTS13, vWF, and complement genes in a patient with NCIPH who had decreased secretion and activity of ADAMTS13 protein. Further studies are needed in NCIPH patients in this regard.
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Moreira DC, Ng CJ, Quinones R, Liang X, Chung DW, Di Paola J. Microangiopathic hemolytic anemia due to ADAMTS-13 loss in idiopathic systemic capillary leak syndrome. J Thromb Haemost 2016; 14:2353-2355. [PMID: 27622772 PMCID: PMC6553946 DOI: 10.1111/jth.13506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Indexed: 12/11/2022]
Abstract
Essentials Idiopathic systemic capillary leak syndrome (SCLS) is characterized by episodes of vascular leakage. We present the case of a patient with SCLS who developed microangiopathic hemolytic anemia (MAHA). We propose that this anemia is the result of ADAMTS-13 loss in the third-space fluid. This suggests that MAHA can occur in patients with significant extravasation of proteins. SUMMARY Idiopathic systemic capillary leak syndrome (SCLS) is a rare process characterized by acute and recurrent episodes of vascular leakage with severe hypotension, hypoalbuminemia, hemoconcentration and edema. Anemia and thrombocytopenia are not part of this syndrome, but here we present the case of a pediatric patient with a clinical presentation consistent with SCLS who subsequently developed microangiopathic hemolytic anemia at a time when she had significant fluid loss and anasarca. Based on serial ADAMTS-13 levels, we propose that the anemia in this patient developed as a result of ADAMTS-13 loss in the third-space fluid, a novel mechanism for acquired microangiopathic hemolytic anemia.
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Affiliation(s)
- D C Moreira
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - C J Ng
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - R Quinones
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - X Liang
- Department of Pathology, University of Colorado, AMC, Aurora, CO, USA
| | - D W Chung
- Bloodworks Research Institute -Puget Sound, Seattle, WA, USA
| | - J Di Paola
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
- Human Medical Genetics and Genomics Program, University of Colorado, Aurora, CO, USA
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Gangaraju R, Rodgers GM. Upshaw-Schulman syndrome and pregnancy: successful management with plasma infusions. Ann Hematol 2016; 95:1745-6. [PMID: 27452869 DOI: 10.1007/s00277-016-2755-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/06/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Radhika Gangaraju
- Division of Hematology and Hematologic Malignancies, University of Utah Health Sciences Center, Salt Lake City, UT, 84112, USA.
- Hematology-Oncology, University of Utah, 2000 Circle of Hope Suite 2100, Salt Lake City, UT, 84112, USA.
| | - George M Rodgers
- Division of Hematology and Hematologic Malignancies, University of Utah Health Sciences Center, Salt Lake City, UT, 84112, USA
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Genotyping of the c.1423C>T (p.P475S) polymorphism in the ADAMTS13 gene by APLP and HRM assays: Northeastern Asian origin of the mutant. Leg Med (Tokyo) 2016; 21:1-4. [PMID: 27497325 DOI: 10.1016/j.legalmed.2016.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/25/2016] [Accepted: 04/28/2016] [Indexed: 12/27/2022]
Abstract
ADAMTS13 is a von Willebrand factor-cleaving protease. The mutant types of p.P475S (c.1423C>T) polymorphism in ADAMTS13 have a reduced activity in comparison with the wild type. In the present study, we investigated the frequency of the C-to-T substitution in 2584 genomic DNA samples from 25 Asian, European, and African populations using APLP (amplified product length polymorphism) and/or HRM (high-resolution melting) assays. Allele T (ADAMTS13(∗)T) was detected only in Asian populations and its frequency was observed to decrease gradually from north to south in 24 East Asian populations. Almost all ADAMTS13(∗)T were associated with ABO(∗)O. These results suggested that ADAMTS13(∗)T had occurred on a chromosome with ABO(∗)O in a northern part of East Asia. This SNP is useful as an ancestry-informative marker, and the present genotyping techniques are applicable to the investigation of an association between this SNP and aortic dissection (Kobayashi et al., 2012).
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18
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Tersteeg C, Verhenne S, Roose E, Schelpe AS, Deckmyn H, De Meyer SF, Vanhoorelbeke K. ADAMTS13 and anti-ADAMTS13 autoantibodies in thrombotic thrombocytopenic purpura – current perspectives and new treatment strategies. Expert Rev Hematol 2015; 9:209-21. [DOI: 10.1586/17474086.2016.1122515] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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19
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Kim HY, Lee KO, Yoo KH, Kim SH, Oh D, Kim HJ. Congenital thrombotic thrombocytopenic purpura (Upshaw-Schulman syndrome) caused by novelADAMTS13mutations. Br J Haematol 2015; 173:156-9. [DOI: 10.1111/bjh.13564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Hyun-Young Kim
- Department of Laboratory Medicine and Genetics; Samsung Medical Centre; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Ki-O Lee
- Samsung Biomedical Research Institute; Samsung Medical Centre; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Keon Hee Yoo
- Department of Paediatrics; Samsung Medical Centre; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sun-Hee Kim
- Department of Laboratory Medicine and Genetics; Samsung Medical Centre; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Doyeun Oh
- Department of Internal Medicine; School of Medicine; CHA University; Seongnam Korea
| | - Hee-Jin Kim
- Department of Internal Medicine; School of Medicine; CHA University; Seongnam Korea
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