Thrombotic thrombocytopenic purpura associated with severe acute pancreatitis in a context of decreased ADAMTS13 activity: a case report

A rare case of thrombotic microangiopathy triggered by acute pancreatitis

Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.

Long-term remission of recurrent thrombotic thrombocytopenic purpura (TTP) after Rituximab in children and young adults

INTRODUCTION

Acquired thrombotic-thrombocytopenic purpura (TTP) is an autoimmune disorder characterized by autoantibodies directed against the von Willebrand metalloprotease. Depletion of B-cells can prevent synthesis of this antibody and presumably induce remission of the disease. In adults, Rituximab (RTX) was effective in relapsed or refractory acute idiopathic TTP.

PROCEDURE

We report the long-term follow-up of five children and two adolescents (age at diagnosis 6-19 years, median 15 years) who were treated with RTX for recurrent or refractory TTP. Some of the patients suffered from recurrent refractory TTP with long histories of previous unsuccessful treatments. One had TTP associated with pancreatitis.

RESULTS

Three patients have been in complete remission after one treatment course with RTX. Four relapsed after 1 to 5 years, respectively, and responded to additional courses of RTX. One of them is in long-term remission after a third course of RTX and splenectomy. Compared to literature reports with a median follow up of 1.4 years (3-46 month), follow-up of our patients after treatment with RTX was very long (2-12.7 years, median 7.7 years). RTX therapy could induce long-term remissions in children with refractory recurrent TTP. Median duration of remission was longer and relapses per patient-years less frequent in patients receiving RTX compared to patients not receiving it. Remissions were achieved in children within one week, much faster than in adults.

CONCLUSION

Because of the rapid induction of remissions, RTX may be suitable for first-line therapy in pediatric acquired antibody-mediated TTP.

Lessons from acute pancreatitis-induced thrombotic thrombocytopenic purpura

Acute pancreatitis is an inflammatory disease characterized by local tissue injury which can trigger a systemic inflammatory response. There is increasing evidence that endothelial dysfunction is one of the critical pathophysiologic manifestations in patients with severe form of acute pancreatitis. In keeping with this, there have been recent reports of a haematological disorder, thrombotic thrombocytopenic purpura (TTP), as being precipitated by acute pancreatitis. However, the patients who develop TTP, secondary to acute pancreatitis, do not always have the characteristic low levels of VonWillebrand multimer cleaving enzyme, ADAMTS-13 suggesting the involvement of other pathophysiological factors. On the contrary, the occurrence of acute pancreatitis in haemolytic diseases may suggest TTP as being a precipitating factor for the pancreatic inflammatory state. This review focuses on the association of these two conditions which have given insights into the role players and the pathogenic mechanisms leading to the development of either of these conditions.