Ulcerative colitis and thrombotic thrombocytopenic purpura

Thrombotic Thrombocytopenic Purpura and Ulcerative Colitis - A Potential Link Revisited

Inflammatory bowel disease is known to be associated with several extraintestinal manifestations including haematological abnormalities. The association between ulcerative colitis and thrombotic thrombocytopenic purpura is largely anecdotal, described in only two case reports so far. While the existence of association remains a matter of research, what is clear is the need for prompt recognition of this complication and expedient treatment which may be life-saving. Here, we describe a patient with ulcerative colitis who developed thrombotic thrombocytopenic purpura.

Complete ADAMTS13 remission in a patient with refractory autoimmune-mediated thrombotic thrombocytopenic purpura after infliximab

Autoimmune thrombotic thrombocytopenic purpura (aTTP) is caused by autoantibodies to the von Willebrand Factor cleaving enzyme, ADAMTS13. Despite recent advances in the treatment of acute aTTP, relapse rates remain high. Guidance for the treatment of patients in clinical remission but with persistent severe ADAMTS13 deficiency who fail to respond to rituximab remains unclear. We report a case of a 29-year-old man diagnosed with aTTP at the age of 11. Over a period of 18 years, he had five clinical relapses with persistent severe ADAMTS13 deficiency (<10%) and presence of autoantibodies during clinical remissions despite immunosuppressive therapy with rituximab, bortezomib and azathioprine. While in a clinical remission, he was diagnosed with Crohn's disease and initially treated with adalimumab. When he subsequently developed antibodies to adalimumab, he was transitioned to infliximab. ADAMTS13 activity increased to 24% by 2 months of infliximab induction, and four months later the ADAMTS13 activity improved to 42%. This case demonstrates the importance of managing concurrent inflammatory disorders and suggests that TNF may play a role in autoantibody development and ADAMTS13 depletion.

Successful use of TNFα blockade in a severe case of idiopathic non-granulomatous ulcerative jejunoileitis associated with thrombotic thrombocytopenic purpura

We describe the case of 50-year-old female patient who presented with severe gastrointestinal symptoms and progressive weight loss of unknown origin. Shortly after admission, she developed an acute flare of thrombotic thrombocytopaenic purpura (TTP) that had to be treated by plasma exchange therapy and rituximab administration. While the signs of TTP subsided, the gastrointestinal symptoms worsened with abdominal cramps, massive gastric retention, malnourishment and a stenosis due to extensive inflammation and wall thickening of the small bowel. Extensive diagnostic efforts yielded no specific cause, so the patient-based on the histopathological findings-was diagnosed with idiopathic non-granulomatous ulcerative jejunoileitis. Following a highly complicated clinical course over several months, successful remission of the inflammatory activity and recovery of the patient could be obtained by TNF-alpha blockade.

Combination vincristine and plasma exchange as initial therapy in patients with thrombotic thrombocytopenic purpura: one institution's experience and review of the literature

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) was once a highly fatal disease with mortality reaching nearly 95 percent; however, application of therapeutic plasma exchange (TPE) has dramatically increased survival. Nevertheless, mortality remains substantial (10%-30% in many published reports), requiring the search for more efficacious treatments. Vincristine (VCR) has been generally reserved for refractory TTP. Despite its effectiveness in a salvage mode, VCR has not been widely advocated as first-line therapy in conjunction with TPE. We previously reported improved survival when VCR and TPE were administered at presentation in patients treated from 1979 to 1994. Utilizing this standardized approach, outcomes of an additional group of patients and the results of a literature review of VCR therapy for TTP are reported.

STUDY DESIGN AND METHODS

Medical records of all patients with a diagnosis of TTP treated between 1995 and 2002 at Cedars-Sinai Medical Center were reviewed. TPE was performed daily, exchanging 1.25 plasma volumes, until the platelet count normalized. Patients received VCR 1.4 mg/m2, (up to 2.0 mg total dose) after the first TPE. A literature review of all publications utilizing VCR in the management of TTP was performed with MEDLINE.

RESULTS

Twelve consecutive patients meeting the diagnostic criteria received treatment with VCR and TPE. All patients achieved durable remission. Patients tolerated VCR without significant complications.

CONCLUSION

Our 100 percent survival rate, as well as evidence garnered from the literature review, suggests that combination therapy with VCR and TPE at presentation might be more effective than TPE alone and therefore warrants consideration as first-line therapy for TTP patients.

First two patients with ulcerative colitis who developed classical thrombotic thrombocytopenic purpura successfully treated with medical therapy and plasma exchange

The association of ulcerative colitis (UC) and thrombotic thrombocytopenic purpura (TTP) is rare. Only one prior patient with these two syndromes has been reported in the literature. In that case, splenectomy and proctectomy were performed to control the symptoms of TTP. We present two patients with UC who developed TTP and were successfully treated with multiple plasma exchanges (PEXs) in conjunction with medical therapy without the necessity for surgical intervention. Acquired TTP may be another extraintestinal autoimmune feature of UC. TTP in association with UC may be refractory to high-dose steroids and PEX, possibly requiring vincristine and splenectomy, as in the one previously reported case, to achieve remission.

A case of Evans' syndrome in a patient with ulcerative colitis

The case of a 37-year-old male diagnosed 16 years previously with ulcerative colitis, admitted on account of hemolytic anaemia and thrombocytopaenia that responded to immunosuppressive therapy, is reported. Despite various peculiarities discussed, this may be the first reported case of Evans' syndrome associated with ulcerative colitis.

Colitis ulcerosa asociada a púrpura trombocitopénica idiopática

Multiple hematological anomalies have been described in association with chronic inflammatory bowel disease. Idiopathic thrombocytopenic purpura is an autoimmune disease characterized by the presence of isolated thrombopenia with a normal or increased number of megakaryocytes in bone marrow and absence of splenomegaly. Several case reports of idiopathic thrombocytopenic purpura associated with chronic inflammatory bowel disease, mostly ulcerative colitis, have been published in the literature. The pathogenic mechanism through which these entities are associated is unknown. Several treatments have been used, varying from short courses of steroids to the use of immunosuppressive agents and splenectomy, depending on the severity of the symptoms. We describe the case of a woman with ulcerative colitis and idiopathic thrombocytopenic purpura, in which the latter first presented when the patient was undergoing treatment with corticosteroids and cyclosporin, one of the therapeutic options for controlling thrombopenic purpura. Platelet deficiency persisted despite treatment with azathioprine and colectomy, also described as a possible curative treatment.