Multifocal serous detachments as the presenting sign of thrombotic thrombocytopenic purpura

PROFOUND VISUAL RECOVERY AT 16 MONTHS AFTER RESOLUTION OF SEROUS RETINAL DETACHMENTS SECONDARY TO THROMBOTIC THROMBOCYTOPENIC PURPURA: CASE REPORT AND LITERATURE REVIEW

PURPOSE

To report a unique case of dramatic improvement in objective visual function during the recovery phase, after resolution of thrombotic thrombocytopenic purpura-related serous retinal detachments and to review prognostic trends in reported cases involving the macula.

METHODS

Observational case report and literature review.

RESULTS

A 36-year-old white woman with thrombotic thrombocytopenic purpura developed vision loss from serous retinal detachments in both eyes. Over a 16-month period, after both retinae remained attached, best-corrected visual acuity improved from 20/400 to 20/50 in both eyes with dramatic improvement on optical coherence tomography and autofluorescence imaging.

CONCLUSION

Although thrombotic thrombocytopenic purpura is a life-threatening illness, visual prognosis in patients with macula off serous retinal detachments appears excellent. Most cases reviewed in literature improved to baseline visual acuity, but recovery periods ranged from days to many months. Hyperautofluorescent granularity on autofluorescence photography may be an indicator of chronic retinal detachment and a more delayed visual recovery.

Renal and pulmonary thrombotic microangiopathy triggered by proteasome-inhibitor therapy in patient with smoldering myeloma: A renal biopsy and autopsy case report

RATIONALE

Thrombotic microangiopathy (TMA) is a group of clinical syndromes characterized by excessive platelet activation and endothelial injury that leads to acute or chronic microvascular obliteration by intimal mucoid and fibrous thickening, with or without associated thrombi. It frequently involves the kidney but may involve any organ or system at variable frequencies depending on the underlying etiology. Among its numerous causes, drug toxicities and complement regulation abnormalities stand out as some of the most common. A more recently described association is with monoclonal gammopathy. Lung involvement by TMA is infrequent, but has been described in Cobalamin C deficiency and post stem-cell transplantation TMA.

PATIENT CONCERNS

This is the case of a patient with smoldering myeloma who received proteasome-inhibitor therapy due to retinopathy and developed acute renal failure within one week of therapy initiation.

DIAGNOSES

A renal biopsy showed thrombotic microangiopathy. At the time, mild pulmonary hypertension was also noted and presumed to be idiopathic.

INTERVENTIONS

Given the known association of proteasome-inhibitor therapy with thrombotic microangiopathy, Bortezomib was discontinued and dialysis was initiated.

OUTCOMES

Drug withdrawal failed to prevent disease progression and development of end-stage renal disease, as well as severe pulmonary hypertension that eventually lead to the patient's death.

LESSONS

To our knowledge, this is the first reported case of pulmonary involvement by TMA associated with monoclonal gammopathy which appears to have been triggered by proteasome-inhibitor therapy. Clinicians should be aware of this possibility to allow for more prompt recognition of pulmonary hypertension as a potential manifestation of monoclonal gammopathy-associated TMA, especially in patients also receiving proteasome-inhibitors, so that treatment aiming to slow disease progression can be instituted.