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Opie J, Verburgh E, Bailly J, Mayne E, Louw V. Hematological Complications of Human Immunodeficiency Virus (HIV) Infection: An Update From an HIV-Endemic Setting. Open Forum Infect Dis 2024; 11:ofae162. [PMID: 38601746 PMCID: PMC11004791 DOI: 10.1093/ofid/ofae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/17/2024] [Indexed: 04/12/2024] Open
Abstract
Medical professionals, particularly in regions with a high burden of human immunodeficiency virus (HIV), should be alert to the hematological complications of HIV, which may include cytopenias, malignancy, and coagulation disturbances. Patients may present with these conditions as the first manifestation of HIV infection. Hematological abnormalities are often multifactorial with opportunistic infections, drugs, malignancy, and HIV infection itself contributing to the clinical presentation, and the diagnosis should consider all these factors. Life-threatening hematological complications requiring urgent diagnosis and management include thrombotic thrombocytopenic purpura, superior mediastinal syndrome, spinal cord compression, and tumor lysis syndrome due to aggressive lymphoma. Antiretroviral therapy is the therapeutic backbone, including for patients with advanced HIV, in addition to specific therapy for the complication. This article reviews the impact of HIV on the hematological system and provides a clinical and diagnostic approach, including the role of a bone marrow biopsy, focusing on perspectives from sub-Saharan Africa.
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Affiliation(s)
- Jessica Opie
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Estelle Verburgh
- Division of Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Jenique Bailly
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Elizabeth Mayne
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Vernon Louw
- Division of Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
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Moola Y, Cassimjee Z, Dayal C, Chiba S, Ajayi A, Davies M. Thrombotic thrombocytopaenic purpura in the era of HIV: A single-centre experience. South Afr J HIV Med 2023; 24:1504. [PMID: 37928502 PMCID: PMC10623642 DOI: 10.4102/sajhivmed.v24i1.1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/03/2023] [Indexed: 11/07/2023] Open
Abstract
Background Thrombotic thrombocytopaenia purpura (TTP) is a rare disorder which carries a high mortality. HIV is an important cause of TTP. Objectives We assessed the presentation and response to plasma exchange (PEX) by HIV status. Method A single-centre retrospective review of all patients receiving PEX for TTP between 01 January 2010 and 31 December 2019 was undertaken. Demographics and presenting parameters were compared between HIV-associated TTP and other aetiologies using Mann-Whitney U and Kruskal Wallis analysis of variance testing, as appropriate. The effect of aetiology and presenting parameters on PEX duration was modelled using Cox proportional hazards; effect of these variables on mortality and residual renal dysfunction in survivors was analysed using stepwise multivariate regression. Results Uncontrolled HIV infection was the commonest cause (81.9%) of TTP in the 83 patients identified. Thrombocytopaenia was more severe and neurological deficit more frequent in HIV-associated TTP; but renal dysfunction was milder in this group. Aetiology did not influence mortality risk. Aetiological category and presenting parameters did not predict PEX duration. Residual renal dysfunction was less frequent in survivors of HIV-associated TTP. Conclusion HIV is an important cause of TTP in the local context. Haematological and neurological involvement are more severe in HIV-associated TTP. Acceptable survival rates are achievable with PEX even in advanced HIV infection; renal sequalae are less common in this group.
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Affiliation(s)
- Yusuf Moola
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zaheera Cassimjee
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Nephrology, Helen Joseph Hospital, Johannesburg, South Africa
| | - Chandni Dayal
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Nephrology, Helen Joseph Hospital, Johannesburg, South Africa
| | - Sheetal Chiba
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Nephrology, Helen Joseph Hospital, Johannesburg, South Africa
| | - Adekunle Ajayi
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Nephrology, Helen Joseph Hospital, Johannesburg, South Africa
| | - Malcolm Davies
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Nephrology, Helen Joseph Hospital, Johannesburg, South Africa
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Louw S, Jacobson BF, Wiggill TM, Chapanduka Z, Sarah Mayne E. HIV-associated thrombotic thrombocytopenic purpura (HIV-TTP): A practical guide and review of the literature. HIV Med 2022; 23:1033-1040. [PMID: 35373442 PMCID: PMC9790193 DOI: 10.1111/hiv.13305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/03/2022] [Accepted: 03/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP), a serious thrombotic microangiopathy (TMA), is prevalent in the South African HIV-infected population. The exact pathogenesis of HIV-associated TTP (HIV-TTP) is however still unclear with diagnostic and therapeutic inconsistancies. METHODS A systematic review of the published literature regarding HIV-TTP was performed. RESULTS HIV-TTP is still associated with significant morbidity and mortality in Africa despite the availability of anti-retroviral therpy (ART). Diagnosis of HIV-TTP requires the presence of a micro-angiopathic haemolytic anaemia with significant red blood cell schistocytes and thrombocytopenia in the absence of another TMA but background activation of the coagulation system and inflammation in HIV infected people can result in diagnostic anbiguity. Plasma therapy in the form of infusion or exchange is successful but expensive, associated with side-effects and not widely available. Adjuvant immunosuppression therapy may of benefit in patients with HIV-TTP and ART must always be optimised. Endothelial dysfunction caused by chronic inflammation and complement activation most likely contributes to the development of HIV-TTP. CONCLUSION The role of adjuvant immunomodulating therpy, the therapeutic targets and pathogenic contribution from endothelial dysfunction in HIV-TTP requires further investigation.
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Affiliation(s)
- Susan Louw
- Department of Molecular Medicine and HaematologyFaculty of Health SciencesUniversity of Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
| | - Barry Frank Jacobson
- Department of Molecular Medicine and HaematologyFaculty of Health SciencesUniversity of Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
| | - Tracey Monica Wiggill
- Department of Molecular Medicine and HaematologyFaculty of Health SciencesUniversity of Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
| | - Zivanai Chapanduka
- Department of HaematologyUniversity of Stellenbosch and National Health Laboratory ServiceCape TownSouth Africa
| | - Elizabeth Sarah Mayne
- Department of ImmunologyFaculty of Health SciencesUniversity of Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
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Louw S, Jacobson BF, Mayne ES. Distinguishing and overlapping laboratory results of thrombotic microangiopathies in HIV infection: Can scoring systems assist? J Clin Apher 2022; 37:460-467. [PMID: 36054148 PMCID: PMC9804888 DOI: 10.1002/jca.22003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/09/2022] [Accepted: 07/30/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with Human Immunodeficiency Virus (HIV) infection are at risk of thrombotic microangiopathies (TMAs) notably thrombotic thrombocytopenic purpura (TTP) and disseminated intravascular coagulation (DIC). Overlap between laboratory results exists resulting in diagnostic ambiguity. METHODS Routine laboratory results of 71 patients with HIV-associated TTP (HIV-TTP) and 81 with DIC with concomitant HIV infection (HIV-DIC) admitted between 2015 and 2021 to academic hospitals in Johannesburg, South Africa were retrospectively reviewed. Both the PLASMIC and the International Society of Thrombosis and Haemostasis (ISTH) DIC scores were calculated. RESULTS Patients with HIV-TTP had significantly (P < .001) increased schistocytes and features of hemolysis including elevated lactate dehydrogenase (LDH)/upper-limit-of-normal ratio (median of 9 (interquartile range [IQR] 5-12) vs 3 (IQR 2-5)) but unexpectedly lower fibrinogen (median 2.8 (IQR 2.2-3.4) vs 4 g/L (IQR 2.5-9.2)) and higher D-dimer (median 4.8 (IQR 2.4-8.1) vs 3.6 g/L (IQR 1.7-6.2)) levels vs the HIV-DIC cohort. Patients with HIV-DIC were more immunocompromised with frequent secondary infections, higher platelet and hemoglobin levels, more deranged coagulation parameters and less hemolysis. Overlap in scoring systems was however observed. CONCLUSION The laboratory parameter overlap between HIV-DIC and HIV-TTP might reflect a shared pathogenesis including endothelial dysfunction and inflammation and further research is required. Fibrinogen in DIC may be elevated as an acute phase reactant and D-dimers may reflect the extensive hemostatic activation in HIV-TTP. Inclusion of additional parameters in TMA scoring systems such the LDH/upper-limit-of-normal ratio, schistocytes count and wider access to ADAMTS-13 testing may enhance diagnostic accuracy and ensure appropriate utilization of plasma.
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Affiliation(s)
- Susan Louw
- Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand (Wits) and National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Barry Frank Jacobson
- Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand (Wits) and National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Elizabeth Sarah Mayne
- Division of Immunology, Department of Pathology, Faculty of Health SciencesUniversity of the Cape Town (UCT) and National Health Laboratory Service (NHLS)Cape TownSouth Africa
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Thrombotic thrombocytopenic purpura (TTP) in Human immunodeficiency virus (HIV) infected patients: New twists on an old disease. AIDS 2022; 36:1345-1354. [PMID: 35608117 DOI: 10.1097/qad.0000000000003257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Investigate the presence of inflammation, endothelial dysfunction and complement activation in patients with HIV-associated thrombotic thrombocytopenic purpura (HIV-TTP) to support the hypothesis that these processes probably contribute to the development of this thrombotic microangiopathy. DESIGN A prospective, investigational cohort study of 35 consecutive patients diagnosed with HIV-associated TTP presenting to three academic, tertiary care hospitals in Johannesburg, South Africa over 2 years. METHODS The patients with HIV-TTP received therapeutic plasma therapy and supportive treatment. Demographic data, the results of routine investigations and patient outcomes were recorded. Peripheral blood samples were collected prior to and on completion of plasma therapy and the following additional parameters were assessed at both time points: activity of the von Willebrand factor (VWF) cleaving protease, a-disintegrin-and-metalloproteinase-with-thrombospondin-motifs 13 (ADAMTS-13) and the presence of ADAMTS-13 autoantibodies, levels of pro-inflammatory cytokines, interleukin-6 and tumour necrosis factor-alpha, and two endothelial cell adhesion molecules. Complement activation was assessed by sequential measurement of C3 and C4 as well as levels of the complement inhibitor, factor H. RESULTS The inflammatory and endothelial activation markers were significantly (P < 0.001) elevated in the cohort of patients prior to plasma therapy compared with levels on discharge. Complement was activated and normalized with therapy. The ADAMTS-13 levels were reduced with significant auto-antibodies to this protease at presentation. CONCLUSION Inflammation in HIV mediates endothelial damage and complement activation. This study proposes that these processes are probably contributory to the development of HIV-TTP, which can therefore be characterized in part as a complementopathy, resembling TTP-like syndrome.
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da Mata GF, Fernandes DE, Luciano EDP, Sales GTM, Riguetti MTP, Kirsztajn GM. Inflammation and kidney involvement in human viral diseases caused by SARS-CoV-2, HIV, HCV and HBV. J Venom Anim Toxins Incl Trop Dis 2021; 27:e20200154. [PMID: 34381495 PMCID: PMC8323457 DOI: 10.1590/1678-9199-jvatitd-2020-0154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/01/2021] [Indexed: 01/08/2023] Open
Abstract
Inflammation is closely related to renal diseases. This is particularly true for renal diseases caused by infections as in viral diseases. In this review, we highlight the inflammatory mechanisms that underlie kidney dysfunction in SARS-CoV-2, human immunodeficiency (HIV), hepatitis C (HCV), and hepatitis B (HBV) infections. The pathophysiology of renal involvement in COVID-19 is complex, but kidney damage is frequent, and the prognosis is worse when it happens. Virus-like particles were demonstrated mostly in renal tubular epithelial cells and podocytes, which suggest that SARS-CoV-2 directly affects the kidneys. SARS-CoV-2 uses the angiotensin-converting enzyme 2 receptor, which is found in endothelial cells, to infect the human host cells. Critical patients with SARS-CoV-2-associated acute kidney injury (AKI) show an increase in inflammatory cytokines (IL-1β, IL-8, IFN-γ, TNF-α), known as cytokine storm that favors renal dysfunction by causing intrarenal inflammation, increased vascular permeability, volume depletion, thromboembolic events in microvasculature and persistent local inflammation. Besides AKI, SARS-CoV-2 can also cause glomerular disease, as other viral infections such as in HIV, HBV and HCV. HIV-infected patients present chronic inflammation that can lead to a number of renal diseases. Proinflammatory cytokines and TNF-induced apoptosis are some of the underlying mechanisms that may explain the virus-induced renal diseases that are here reviewed.
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Affiliation(s)
- Gustavo Ferreira da Mata
- Department of Medicine (Nephrology), Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Danilo Euclides Fernandes
- Department of Medicine (Nephrology), Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Eduardo de Paiva Luciano
- Department of Medicine (Nephrology), Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil
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Sury K, Perazella MA. The Changing Face of Human Immunodeficiency Virus-Mediated Kidney Disease. Adv Chronic Kidney Dis 2019; 26:185-197. [PMID: 31202391 DOI: 10.1053/j.ackd.2018.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 01/09/2023]
Abstract
In nearly 40 years since human immunodeficiency virus (HIV) first emerged, much has changed. Our understanding of the pathogenesis of HIV infection and its effect on the cells within each kidney compartment has progressed, and the natural history of the disease has been transformed. What was once an acutely fatal illness is now a chronic disease managed with oral medications. This change is largely due to the advent of antiretroviral drugs, which have dramatically altered the prognosis and progression of HIV infection. However, the success of antiretroviral therapy has brought with it new challenges for the nephrologist caring for patients with HIV/acquired immune deficiency syndrome, including antiretroviral therapy-induced nephrotoxicity, development of non-HIV chronic kidney disease, and rising incidence of immune-mediated kidney injury. In this review, we discuss the pathogenesis of HIV infection and how it causes pathologic changes in the kidney, review the nephrotoxic effects of select antiretroviral medications, and touch upon other causes of kidney injury in HIV cases, including mechanisms of acute kidney injury, HIV-related immune complex glomerular disease, and thrombotic microangiopathy.
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Masoet A, Bassa F, Chothia MY. HIV-associated thrombotic thrombocytopaenic purpura: A retrospective cohort study during the anti-retroviral therapy era. J Clin Apher 2019; 34:399-406. [PMID: 30758877 DOI: 10.1002/jca.21692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 11/14/2018] [Accepted: 01/28/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND HIV-associated thrombotic thrombocytopaenic purpura (TTP) is thought to represent the majority of current TTP diagnoses in South Africa (SA). AIM The primary aim was to describe the clinical features and compare the time to remission of TTP in those patients with and without HIV. DESIGN A retrospective cohort study conducted at Tygerberg Hospital in Cape Town, SA for the period January 1, 2010 to January 31, 2015. METHODS All adult patients requiring ≥5 units of plasma products for ≥1 day during hospitalization were screened for a diagnosis of TTP. Those with a reported clinical diagnosis and/or laboratory evidence of TTP were included in the final analysis. RESULTS A total of 52 cases were identified of which 78.8% were HIV-infected. Time to remission was 10 days in the HIV group vs 19 days in the HIV negative group, P = 0.07. Most of the patients were Black females. Fever was more common in those with HIV. Neurological features were common in both groups. The majority in the HIV group was managed exclusively with plasma infusion alone (90.2% vs 45.5%, P < 0.01). There were no differences in the time to remission regardless of treatments received. Anti-retroviral therapy initiation during hospitalization was a predictor for remission. Overall mortality rate was 44.2%. CONCLUSION There was no difference in the time to remission in patients with HIV-associated TTP as compared with HIV negative TTP. The high mortality was probably the result of less intensive plasma infusion and therapeutic plasma exchange regimens.
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Affiliation(s)
- Azizah Masoet
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa
| | - Fatima Bassa
- Division of Haematology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa
| | - Mogamat-Yazied Chothia
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa.,Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa
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Louw S, Gounden R, Mayne ES. Thrombotic thrombocytopenic purpura (TTP)-like syndrome in the HIV era. Thromb J 2018; 16:35. [PMID: 30559606 PMCID: PMC6291936 DOI: 10.1186/s12959-018-0189-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/02/2018] [Indexed: 12/17/2022] Open
Abstract
Background The thrombotic microangiopathies (TMAs) is a heterogeneous group of relatively uncommon but serious disorders presenting with thrombocytopenia and microangiopathic haemolysis. Thrombotic thrombocytopenic purpura (TTP) is one of these microangiopathic processes. HIV infection is an acquired cause of TTP but the pathogenesis is poorly understood. HIV-associated TTP was previously described to be associated with advanced immunosuppression. The incidence of HIV-related TTP was expected to decline with access to anti-retroviral therapy (ART). Methods We undertook an observational study of patients with a diagnosis of TTP admitted to our hospital (CMJAH). The patient demographics, laboratory test results and treatment outcomes were recorded. Results Twenty-one patients were admitted with a diagnosis of TTP during the study period. All patients had schistocytes and severe thrombocytopaenia. The presenting symptoms were non-specific and renal dysfunction and neurological compromise were uncommon. 77% of the patients were HIV-infected and, in 7 patients, TTP was the index presentation. The remainder of the HIV infected patients were on ART and the majority were virologically suppressed. A significant female preponderance was present. Only 4 of the 21 patients tested HIV negative with a positive Coombs test in 2. All patients in this cohort received treatment with plasma exchange therapy for a median period of 12 days with a 96.5% survival rate. Neither the baseline laboratory features nor the degree of immunosuppression was predictive of the duration of therapy needed for remission. Conclusion HIV-related TTP is still a cause of morbidity and the clinical presentation is heterogeneous which may present a diagnostic challenge in the absence of sensitive biomarkers. Early treatment with plasma exchange is effective but expensive and invasive.
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Affiliation(s)
- Susan Louw
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand and National Health Laboratory Service, Office 3B20, 7 York Road, Parktown, Johannesburg, 2191 South Africa
| | - Reenelle Gounden
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand and National Health Laboratory Service, Office 3B20, 7 York Road, Parktown, Johannesburg, 2191 South Africa
| | - Elizabeth Sarah Mayne
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand and National Health Laboratory Service, Office 3B20, 7 York Road, Parktown, Johannesburg, 2191 South Africa
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Swart L, Schapkaitz E, Mahlangu JN. Thrombotic thrombocytopenic purpura: A 5-year tertiary care centre experience. J Clin Apher 2018; 34:44-50. [PMID: 30536422 DOI: 10.1002/jca.21673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is associated with high mortality if not managed timeously with therapeutic plasma exchange (TPE). TTP secondary to human immunodeficiency virus (HIV) infection is unique to sub-Saharan Africa. The management and outcome of TTP in the era of improved access to therapy has not been described. METHODS The present study describes the clinical presentation, treatment, therapeutic endpoints, and outcome of TTP patients at the Charlotte Maxeke Johannesburg Academic Hospital, South Africa. The inpatient and outpatient records of 41 consecutive adults with TTP were reviewed between 2012 and 2016. Patients were classified according to aetiology and treatment response. RESULTS TTP was the initial presenting feature of HIV infection in 78.0%, and 12.5% were noncompliant with antiretroviral therapy (ART). Most study patients were of black ethnicity (95%) and female gender (78.1%). Treatment included initial TPE (87.8%), plasma infusion (78.1%), antiretroviral therapy (78.3%), corticosteroids (61.0%) intensive care admission (41.5%), renal dialysis (12.2%), and other immunosuppressive agents (4.9%). The median (range) number of TPEs was 10.0 (7.0-15.0). A high rate of refractory disease (63.4%) was reported. Haemoglobin, platelet count, lactate dehydrogenase, red cell distribution width, and creatinine were reliable therapeutic end-points (P < .05). The relapse rate was 9.8% and the mortality rate was 29.3%. CONCLUSION The high mortality rate emphasises the importance of early diagnosis, referral, and appropriate management of TTP. Anti-retroviral therapy and adherence monitoring are essential to TTP management associated with HIV. Future studies to identify patients at risk for refractory disease are indicated.
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Affiliation(s)
- Léanne Swart
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
| | - Elise Schapkaitz
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
| | - Johnny N Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
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Schapkaitz E, Schickerling TM. The Diagnostic Challenge of Acquired Thrombotic Thrombocytopenic Purpura in Children: Case Report and Review of the Literature. Lab Med 2018; 49:268-271. [PMID: 29659973 DOI: 10.1093/labmed/lmy015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a rare disease in children. Despite advances in diagnosis and treatment, acquired TTP remains a challenging disease due to the lack of a simple diagnostic test and the variable response to plasma exchange. Herein, we describe a case of a 5-year-old of black ethnicity boy who presented with a sudden onset of fatigue and body aches. Laboratory investigations revealed a thrombotic microangiopathic manifestation. TTP was diagnosed, and plasma exchange and corticosteroids were initiated, with an excellent response. Subsequently, reduced disintegrin and metalloprotease with thrombospodin-2-like repeats (ADAMTS-13) activity and human immunodeficiency virus (HIV) were confirmed. Antiretroviral treatment was started as long-term management. At last follow-up, he continues in stable remission.
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Affiliation(s)
- Elise Schapkaitz
- Department of Hematology and Molecular Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanya Marié Schickerling
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Bade NA, Giffi VS, Baer MR, Zimrin AB, Law JY. Thrombotic microangiopathy in the setting of human immunodeficiency virus infection: High incidence of severe thrombocytopenia. J Clin Apher 2018; 33:342-348. [PMID: 29377224 DOI: 10.1002/jca.21615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) infection increases the risk of thrombotic microangiopathy (TMA), but TMA in the setting of HIV infection is not well characterized. The experience with TMA in the setting of HIV infection at the University of Maryland Medical Center was reviewed. STUDY DESIGN AND METHODS Patients undergoing therapeutic plasma exchange (TPE) for TMA from January 1, 2000 through December 31, 2012 were reviewed. Those with known HIV-positive and -negative status were compared. RESULTS Among 102 patients with known HIV status, 28 (27%) were HIV-positive, including 3 with previously undiagnosed HIV. HIV-positive patients had a median viral load of 89 500 copies/mL (range, 0->750 000 copies/mL) and a median CD4 count of 58 cells/µL (range, 2-410 cells/µL). Compared to HIV-negative patients, HIV-positive patients more frequently presented with concurrent infections (60.7% vs. 23.7%; P = .0007), had a trend toward lower median platelet counts (3000/µL vs. 15 000/µL; P = .07) and more frequently had platelet counts less than 10 000/mcL (P = .02). Nevertheless, number of TPE procedures required for remission, remission rate, mortality, and relapse incidence were similar in HIV-positive and HIV-negative patients. CONCLUSIONS The incidence described herein of HIV infection among TMA patients is the highest reported outside of South Africa. More severe thrombocytopenia in HIV-positive patients may reflect TMA in the setting of preexisting HIV-associated thrombocytopenia. HIV should be considered in patients with TMA, and TMA should be considered in HIV-positive patients with severe thrombocytopenia.
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Affiliation(s)
- Najeebah A Bade
- Division of Hematology/Oncology, Department of Medicine, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201
| | - Victoria S Giffi
- Division of Hematology/Oncology, Department of Medicine, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201
| | - Maria R Baer
- Division of Hematology/Oncology, Department of Medicine, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201
| | - Ann B Zimrin
- Division of Hematology/Oncology, Department of Medicine, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201
| | - Jennie Y Law
- Division of Hematology/Oncology, Department of Medicine, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, Maryland, 21201
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Hematologic Manifestations of HIV/AIDS. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Coppo P. [Secondary thrombotic microangiopathies]. Rev Med Interne 2017; 38:731-736. [PMID: 28890263 DOI: 10.1016/j.revmed.2017.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMA) are termed secondary when associated to a specific context favouring their occurrence. They encompass mainly TMA associated with pregnancy, allogeneic hematopoietic stem cell transplantation, cancer, drugs, or HIV infection. Secondary TMA represent a heterogeneous group of diseases which clinical presentation largely depends on the associated context. It is therefore mandatory to recognize these conditions since they have a significant impact in TMA management and prognosis. A successful management still represents a challenge in secondary TMA. Significant progresses have been made in the understanding of pregnancy-associated TMA, allowing an improvement of prognosis; on the opposite, other forms of secondary TMA such as hematopoietic stem cell transplantation-associated TMA or TMA associated with chemotherapy remain of dismal prognosis. A better understanding of pathophysiology in these forms of TMA, in association with a more empirical approach through the use of new therapeutic agents that can also help in the understanding on new mechanisms a posteriori, should improve their prognosis. The preliminary encouraging results reported with complement blockers in this field could represent a convincing example.
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Affiliation(s)
- P Coppo
- Service d'hématologie, centre de référence des microangiopathies thrombotiques, hôpital Saint-Antoine, UPMC université Paris 6, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
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- Service d'hématologie, centre de référence des microangiopathies thrombotiques, hôpital Saint-Antoine, UPMC université Paris 6, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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15
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Bendapudi PK, Hurwitz S, Fry A, Marques MB, Waldo SW, Li A, Sun L, Upadhyay V, Hamdan A, Brunner AM, Gansner JM, Viswanathan S, Kaufman RM, Uhl L, Stowell CP, Dzik WH, Makar RS. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. LANCET HAEMATOLOGY 2017; 4:e157-e164. [PMID: 28259520 DOI: 10.1016/s2352-3026(17)30026-1] [Citation(s) in RCA: 266] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among the syndromes characterised by thrombotic microangiopathy, thrombotic thrombocytopenic purpura is distinguished by a severe deficiency in the ADAMTS13 enzyme. Patients with this disorder need urgent treatment with plasma exchange. Because ADAMTS13 activity testing typically requires prolonged turnaround times and might be unavailable in resource-poor settings, a method to rapidly assess the likelihood of severe ADAMTS13 deficiency is needed. METHODS All consecutive adult patients presenting to three large academic medical centres in Boston, MA, USA, with thrombotic microangiopathy and a possible diagnosis of thrombotic thrombocytopenic purpura between Jan 8, 2004, and Dec 6, 2015, were included in an ongoing multi-institutional registry (the Harvard TMA Research Collaborative). Univariate analysis was used to identify covariates for a logistic regression model predictive of severe ADAMTS13 deficiency (≤10% activity). A clinical point score was generated, and its diagnostic performance was assessed using internal and external validation cohorts and compared to clinical assessment alone. FINDINGS 214 patients with thrombotic microangiopathy were included in the derivation cohort. A seven-component clinical prediction tool, termed the PLASMIC score, was developed and found to reliably assess the pretest probability of severe ADAMTS13 deficiency (C statistic 0·96, 95% CI 0·92-0·98). Our diagnostic model was reproducibly accurate in both the internal (0·95, 0·91-0·98) and external (0·91, 0·85-0·95) validation cohorts. The scoring system also more consistently diagnosed thrombotic microangiopathy due to severe ADAMTS13 deficiency than did standard clinical assessment, as measured by C statistic (0·96, 95% CI 0·92-0·98 for PLASMIC vs 0·83, 0·77-0·88 for clinical assessment; p<0·0001) and mean Brier score (0·065 for PLASMIC vs 0·111 for clinical assessment; mean paired difference 0·05, 95% CI 0·01-0·08; p<0·0001). When utilised in addition to clinical assessment, the PLASMIC score contributed significant discriminatory power (integrated discrimination improvement 0·24, 95% CI 0·11-0·37). INTERPRETATION We have developed and validated a clinical prediction tool-the PLASMIC score-to stratify patients with thrombotic microangiopathy according to their risk of having severe ADAMTS13 deficiency. We have shown that this scoring system is superior to standard clinical assessment in addressing the diagnostic challenge presented by thrombotic microangiopathy. Its use, together with clinical judgment, may facilitate treatment decisions in patients for whom timely results of ADAMTS13 activity testing are unavailable. FUNDING The Luick Family Fund of Massachusetts General Hospital.
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Affiliation(s)
- Pavan K Bendapudi
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA; Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ashley Fry
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen W Waldo
- Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA
| | - Ang Li
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lova Sun
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Vivek Upadhyay
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ayad Hamdan
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Andrew M Brunner
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John M Gansner
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Srinivas Viswanathan
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Richard M Kaufman
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lynne Uhl
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christopher P Stowell
- Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Walter H Dzik
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA; Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Robert S Makar
- Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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16
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Warner NC, Vaughan LB, Wenzel RP. Human immunodeficiency virus associated thrombotic thrombocytopenic purpura, a clinical conundrum. J Clin Apher 2016; 32:567-570. [DOI: 10.1002/jca.21514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Nathaniel C. Warner
- Department of Internal Medicine; Virginia Commonwealth University; 5017 Caledonia Rd, Richmond Virginia 23225
| | - Leroy B. Vaughan
- Division of Infectious Diseases; Virginia Commonwealth University; Richmond Virginia
| | - Richard P. Wenzel
- Division of Infectious Diseases; Virginia Commonwealth University; Richmond Virginia
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17
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Saab KR, Elhadad S, Copertino D, Laurence J. Thrombotic Microangiopathy in the Setting of HIV Infection: A Case Report and Review of the Differential Diagnosis and Therapy. AIDS Patient Care STDS 2016; 30:359-64. [PMID: 27509235 DOI: 10.1089/apc.2016.0124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Before the modern era of HIV/AIDS therapeutics, which enabled a cascade of early recognition of infection, prompt initiation of effective antiretroviral therapies, and close follow-up, severe forms of microvascular clotting disorders known as thrombotic microangiopathies (TMAs) were frequent in the setting of advanced HIV disease. Their incidence was as high as 7% in the period 1984-1999, but fell dramatically, to <0.5%, by 2002. This profound change was predicated on one critical development: availability of new classes of anti-HIV drugs, enabling reduction and maintenance of HIV viral loads to undetectable levels. Another development in the period 1999-2002 related to TMA therapy: with recognition of autoantibodies against the von Willebrand factor cleaving protease ADAMTS13 as the etiology of most cases of one major form of TMA, thrombotic thrombocytopenic purpura, it permitted appropriate use of life-saving interventions based on plasma exchange and immune suppression. A more recent factor in TMA therapeutics was the 2011 approval by the US FDA and European EMA of eculizumab, a humanized monoclonal antibody against complement component C5, for the treatment of atypical hemolytic uremic syndrome, another major form of TMA. Despite these milestones, life- and organ-threatening TMAs still occur in untreated HIV disease and, to a much lesser extent, in those patients with suppressed viral loads. Confusion in terms of the differential diagnosis of these TMAs also impedes use of directed treatments. This report utilizes a case study of a young woman with advanced AIDS who presented with a severe TMA, characterized by coma and renal failure, to highlight the diagnostic and therapeutic challenges raised by complex hematologic conditions occurring in the setting of HIV.
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Affiliation(s)
- Karim R. Saab
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sonia Elhadad
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Dennis Copertino
- Hunter College of the City University of New York, New York, New York
| | - Jeffrey Laurence
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, New York
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18
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Abstract
Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.
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Affiliation(s)
- Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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19
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Affiliation(s)
- B I Chosamata
- Department of Pathology and Laboratory Science, College of Medicine, University of Malawi, Blantyre, Malawi
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20
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Prevalence of E. coli O157:H7 in water sources: an overview on associated diseases, outbreaks and detection methods. Diagn Microbiol Infect Dis 2015; 82:249-64. [DOI: 10.1016/j.diagmicrobio.2015.03.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/28/2015] [Accepted: 03/22/2015] [Indexed: 11/21/2022]
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21
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Allie S, Stanley A, Bryer A, Meiring M, Combrinck MI. High levels of von Willebrand factor and low levels of its cleaving protease, ADAMTS13, are associated with stroke in young HIV-infected patients. Int J Stroke 2015; 10:1294-6. [PMID: 26121272 DOI: 10.1111/ijs.12550] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/08/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Stroke associated with human immunodeficiency virus infection may occur through a variety of mechanisms. Von Willebrand factor is a marker of endothelial dysfunction, and is elevated in human immunodeficiency virus infection. High levels of von Willebrand factor, a protein involved in platelet adhesion and aggregation, and low levels of ADAMTS13, a metalloproteinase that cleaves von Willebrand factor, have been associated with an increased risk of thrombosis. AIM To investigate the role of von Willebrand factor and ADAMTS13 in the pathogenesis of human immunodeficiency virus-related stroke in young patients. METHODS A case-control study (n = 100) comprising three participant groups: human immunodeficiency virus-positive antiretroviral therapy-naïve young strokes (n = 20), human immunodeficiency virus-negative young strokes (n = 40), and human immunodeficiency virus-positive antiretroviral therapy-naïve nonstroke controls (n = 40). von Willebrand factor and ADAMTS13 levels were measured in plasma samples collected five- to seven-days poststroke. RESULTS Human immunodeficiency virus-positive stroke participants had higher von Willebrand factor levels than human immunodeficiency virus-negative strokes (173·5% vs. 135%, P = 0·032). They tended to have higher levels of von Willebrand factor than human immunodeficiency virus-positive nonstroke controls (173·5% vs. 129%, P = 0·061). Human immunodeficiency virus-positive stroke participants had lower levels of ADAMTS13 than human immunodeficiency virus-positive nonstroke controls (0% vs. 23·5% P = 0·018) most likely due to the effect of the acute stroke. However, in the nonstroke group, these levels were significantly reduced compared with population norms. von Willebrand factor levels in all human immunodeficiency virus-positive participants were negatively correlated with CD4 counts. CONCLUSIONS Stroke in human immunodeficiency virus infection is associated with a prothrombotic state, characterized by elevated von Willebrand factor and low ADAMTS13 levels.
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Affiliation(s)
- Sameera Allie
- Division of Neurology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Alan Stanley
- Division of Neurology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Alan Bryer
- Division of Neurology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Muriel Meiring
- Department of Haematology and Cell Biology, University of Free State, Bloemfontein, South Africa
| | - Marc I Combrinck
- Division of Neurology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.,Division of Geriatric Medicine, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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22
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Tasaki T, Yamada S, Nabeshima A, Noguchi H, Nawata A, Hisaoka M, Sasaguri Y, Nakayama T. An autopsy case of myocardial infarction due to idiopathic thrombotic thrombocytopenic purpura. Diagn Pathol 2015; 10:52. [PMID: 26022055 PMCID: PMC4446843 DOI: 10.1186/s13000-015-0285-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/22/2015] [Indexed: 01/16/2023] Open
Abstract
UNLABELLED Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder characterized by systemic platelet-von Willebrand factor aggregation, organ ischemia and profound thrombocytopenia. In this report, we describe an autopsy case of a 77-year-old Japanese man diagnosed with idiopathic TTP. He had no history of cardiovascular disease symptoms, such as chest pain, ST segment elevation, and elevation of cardiac enzyme levels, except arrhythmia. The patient suddenly died despite receiving many treatments. On autopsy, macroscopically and microscopically, acute and chronic myocardial infarction manifested as petechiae and fibrotic foci and covered a wide area in the myocardium, including the area near the atrioventricular node. The microthrombi in the small arterioles and capillaries were platelet thrombi, which showed positive results for periodic acid-Schiff stain and factor VIII on immunohistochemical staining. The cause of the sudden death was suspected to be myocardial infarction, including a cardiac conduction system disorder due to multiple platelet microthrombi. Asymptomatic myocardial infarction is an important cause of death in TTP. Therefore, the heart tissue, including the sinus-atrial node and the atrioventricular node, should be microscopically examined more closely in autopsy cases of patients with TTP who experienced sudden death of TTP. This report is a critical teaching case considering that its cause of sudden death may be arrhythmia due to a myocardial infarction including cardiac conduction system disorder by platelet microthrombi. VIRTUAL SLIDES The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2113354005156739.
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Affiliation(s)
- Takashi Tasaki
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Sohsuke Yamada
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Atsunori Nabeshima
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Hirotsugu Noguchi
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Aya Nawata
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Masanori Hisaoka
- Pathology and Oncology, University of Occupational and Environmental Health, Kitakyusyu, Japan.
| | | | - Toshiyuki Nakayama
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
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van den Berg K, Murphy EL, Pretorius L, Louw VJ. The impact of HIV-associated anaemia on the incidence of red blood cell transfusion: implications for blood services in HIV-endemic countries. Transfus Apher Sci 2014; 51:10-8. [PMID: 25457008 DOI: 10.1016/j.transci.2014.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cytopaenias, especially anaemia, are common in the HIV-infected population. The causes of HIV related cytopaenias are multi-factorial and often overlapping. In addition, many of the drugs used in the management of HIV-positive individuals are myelosuppresive and can both cause and exacerbate anaemia. Even though blood and blood products are still the cornerstone in the management of severe cytopaenias, how HIV may affect blood utilisation is not well understood. The impact of HIV/AIDS on blood collections has been well documented. As the threat posed by HIV on the safety of the blood supply became clearer, South Africa introduced progressively more stringent donor selection criteria, based on the HIV risk profile of the donor cohort from which the blood collected. The implementation of new testing technology in 2008 which significantly improved the safety of the blood supply enabled the removal of what was perceived by many as a racially based donor risk model. However, this new technology had a significant and sustained impact on the cost of blood and blood products in South Africa. In contrast, it would appear little is known of how HIV influences the utilisation of blood and blood products. Considering the high prevalence of HIV among hospitalised patients and the significant risk for anaemia among this group, there would be an expectation that the transfusion requirements of an HIV-infected patient would be higher than that of an HIV-negative patient. However, very little published data is available on this topic which emphasises the need for further large-scale studies to evaluate the impact of HIV/AIDS on the utilisation of blood and blood products and how the large-scale roll-out of ARV programs may in future play a role in determining the country's blood needs.
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Affiliation(s)
- Karin van den Berg
- South African National Blood Service, Port Elizabeth, South Africa; Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa.
| | - Edward L Murphy
- University of California, San Francisco, United States; Blood Systems Research Institute, San Francisco, United States
| | - Lelanie Pretorius
- Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa; Ampath Laboratories, Bloemfontein, South Africa
| | - Vernon J Louw
- Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
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van den Berg K, van Hasselt J, Bloch E, Crookes R, Kelley J, Berger J, Ingram C, Dippenaar A, Thejpal R, Littleton N, Elliz T, Reubenson G, Cotton M, Hull JC, Moodley P, Goga Y, Eldridge W, Patel M, Hefer E, Bird A. A review of the use of blood and blood products in HIV-infected patients. South Afr J HIV Med 2012; 13:87-104. [PMID: 28479876 PMCID: PMC5419681 DOI: 10.4102/sajhivmed.v13i2.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Despite numerous publications on the appropriate use of blood and blood products, few specifically consider the role of transfusion in the management of HIV. This review is a synthesis of conditions encountered in the management of HIV-infected patients where the transfusion of blood or blood products may be indicated. A consistent message emerging from the review is that the principles of transfusion medicine do not differ between HIV-negative and -positive patients. The aim of the review is to provide clinicians with a practical and succinct overview of the haematological abnormalities and clinical circumstances most commonly encountered in the HIV setting, while focusing on the rational and appropriate use of blood and blood products for HIV patients. Important ethical considerations in dealing with both the collection and transfusion blood and blood products in the HIV era have also been addressed.
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Purpura thrombotique thrombocytopénique et autres syndromes de microangiopathie thrombotique au cours de l’infection par le virus de l’immunodéficience humaine. Rev Med Interne 2012; 33:259-64. [DOI: 10.1016/j.revmed.2011.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 11/04/2011] [Accepted: 11/22/2011] [Indexed: 11/23/2022]
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26
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George JN, Terrell DR, Vesely SK, Kremer Hovinga JA, Lämmle B. Thrombotic microangiopathic syndromes associated with drugs, HIV infection, hematopoietic stem cell transplantation and cancer. Presse Med 2012; 41:e177-88. [DOI: 10.1016/j.lpm.2011.10.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/20/2011] [Indexed: 10/14/2022] Open
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27
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Current management and therapeutical perspectives in thrombotic thrombocytopenic purpura. Presse Med 2012; 41:e163-76. [DOI: 10.1016/j.lpm.2011.10.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/26/2011] [Accepted: 10/28/2011] [Indexed: 12/26/2022] Open
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Thrombotic thrombocytopenic purpura associated with mixed connective tissue disease: a case report. Case Rep Med 2011; 2011:953890. [PMID: 21915182 PMCID: PMC3170900 DOI: 10.1155/2011/953890] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 07/10/2011] [Accepted: 07/13/2011] [Indexed: 11/29/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multisystemic disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia, which may be accompanied by fever, renal, or neurologic abnormalities. Cases are divided into acute idiopathic TTP and secondary TTP. Autoimmune diseases, especially systemic lupus erythematosus, in association with TTP have been described so far in many patients. In contrast, TTP occurring in a patient with mixed connected tissue disease (MCTD) is extremely rare and has only been described in nine patients. We describe the case of a 42-year-old female with MCTD who developed thrombocytopenia, microangiopathic hemolytic anemia, fever, and neurological symptoms. The patient had a good clinical evolution with infusion of high volume of fresh frozen plasma, steroid therapy, and support in an intensive care unit. Although the occurrence of TTP is rare in MCTD patients, it is important to recognize TTP as a cause of thrombocytopenia and hemolytic anemia in any patient with autoimmune diseases. Prompt institution of treatment remains the cornerstone of treatment of TTP even if plasma exchange is not available like what frequently happens in developing countries.
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29
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Egbor M, Johnson A, Harris F, Makanjoula D, Shehata H. Pregnancy-associated atypical haemolytic uraemic syndrome in the postpartum period: a case report and review of the literature. Obstet Med 2011; 4:83-5. [PMID: 27582861 DOI: 10.1258/om.2011.100059] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2011] [Indexed: 12/24/2022] Open
Abstract
Pregnancy has been reported to be a trigger in about 10% of all patients with atypical haemolytic uraemic syndrome (aHUS). However, in contrast to pregnancy-associated thrombotic thrombocytopaenic purpura, the presentation of pregnancy-associated aHUS remains ill defined and can therefore be difficult to diagnose and manage appropriately. Here we report a case of pregnancy-associated relapse of aHUS in a patient with a previous medical history of aHUS prior to pregnancy.
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Affiliation(s)
- M Egbor
- Department of Obstetrics and Gynaecology, Epsom & St Helier University Hospital
| | - A Johnson
- Department of Obstetrics and Gynaecology, Epsom & St Helier University Hospital
| | - F Harris
- Renal Unit, Epsom & St Helier University Hospital , Carshalton , UK
| | - D Makanjoula
- Renal Unit, Epsom & St Helier University Hospital , Carshalton , UK
| | - H Shehata
- Department of Obstetrics and Gynaecology, Epsom & St Helier University Hospital
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30
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Hart D, Sayer R, Miller R, Edwards S, Kelly A, Baglin T, Hunt B, Benjamin S, Patel R, Machin S, Scully M. Human immunodeficiency virus associated thrombotic thrombocytopenic purpura – favourable outcome with plasma exchange and prompt initiation of highly active antiretroviral therapy. Br J Haematol 2011; 153:515-9. [DOI: 10.1111/j.1365-2141.2011.08636.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Daniel Hart
- Department of Haematology, St Bartholomew’s and the London Hospital
| | - Ruth Sayer
- Mortimer Market Centre, Camden Provider Services PCT
| | - Robert Miller
- Research Department of Infection and Population Health, University College London, London
| | - Simon Edwards
- Research Department of Infection and Population Health, University College London, London
| | - Anne Kelly
- Department of Haematology, Addenbrookes Hospital, Cambridge
| | - Trevor Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge
| | - Beverley Hunt
- Department of Haematology, Guys and St Thomas’ NHS Trust, London
| | | | - Raj Patel
- Haematology Department, Kings College Hospital
| | - Samuel Machin
- Haemostasis Research Unit, University College London
| | - Marie Scully
- Department of Haematology, University College London Hospital, London, UK
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31
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Evans MW, Vaughan LB, Giffi VS, Zimrin AB, Hess JR. Rituximab treatment for thrombotic thrombocytopenic purpura associated with human immunodeficiency virus failing extensive treatment with plasma exchange: a report of two cases. AIDS Patient Care STDS 2010; 24:349-52. [PMID: 20515417 DOI: 10.1089/apc.2009.0313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an urban area with a 3% prevalence of HIV infection, two women presented in a 1-year period with AIDS and thrombotic thrombocytopenic purpura (TTP). TTP was diagnosed in each patient based on the presence of thrombocytopenia, schistocytes, and markedly elevated lactate dehydrogenase (LDH) activity. Initial treatment with plasma exchange resulted in resolution of these abnormalities. However, the discontinuation of plasma exchange resulted in the prompt recurrence of laboratory abnormalities diagnostic for TTP. Treatment failure was established after observing 6 and 4 such responses requiring 41 and 40 episodes of plasma exchange for each patient, respectively. Patients were subsequently treated with 2-4 doses of weekly rituximab resulting in durable remission. These patients are now 21 and 9 months beyond rituximab treatment. Rituximab appears to be safe and effective in this setting.
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Affiliation(s)
- Michael W. Evans
- Greenebaum Cancer Center, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
| | - Leroy B. Vaughan
- Department of Medicine, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
| | - Victoria S. Giffi
- Department of Medicine, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
| | - Ann B. Zimrin
- Greenebaum Cancer Center, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
| | - John R. Hess
- Greenebaum Cancer Center, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
- Department of Medicine, University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
- Department of Pathology of the University of Maryland School of Medicine and Medical Center, Baltimore, Maryland
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32
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Visagie GJ, Louw VJ. Myocardial injury in HIV-associated thrombotic thrombocytopenic purpura (TTP). Transfus Med 2010; 20:258-64. [PMID: 20409074 DOI: 10.1111/j.1365-3148.2010.01006.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) has been associated with human immunodeficiency virus (HIV) infection. With the high prevalence of HIV in sub-Saharan Africa, HIV-associated TTP is the most common form of this disease seen in the South African population. Several case reports describe myocardial infarction in HIV-negative TTP patients. The case of the first HIV-positive patient who presented with clinical signs and symptoms of TTP and myocardial injury is reported in this study. A patient with fragmentation haemolysis and thrombocytopenia presented with angina. Risk factors for ischaemic heart disease were absent. An electrocardiogram (EKG) revealed ST-segment elevation and a significantly raised Troponin T level. The patient's HIV test was positive and a diagnosis of myocardial injury with HIV-associated TTP was made. The patient was treated with plasma infusion and steroid therapy. Due to poor response, the therapy was changed to plasma exchange. The patient recovered fully and subsequent coronary angiography revealed normal coronary vessels. Treatment of myocardial infarction in TTP is controversial, but the treatment cornerstone should remain plasma infusion or plasma exchange. As patients are often young and do not have the classical risk factors of ischaemic heart disease, a high level of suspicion and routine exclusion of myocardial ischaemia in these patients are advised.
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Affiliation(s)
- G J Visagie
- Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa.
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33
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Kiss JE. Thrombotic thrombocytopenic purpura: recognition and management. Int J Hematol 2010; 91:36-45. [DOI: 10.1007/s12185-009-0478-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 12/16/2009] [Indexed: 01/01/2023]
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34
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Park YA, Hay SN, Brecher ME. ADAMTS13 activity levels in patients with human immunodeficiency virus-associated thrombotic microangiopathy and profound CD4 deficiency. J Clin Apher 2009; 24:32-6. [PMID: 19156755 DOI: 10.1002/jca.20189] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) encompasses a number of disorders with hemolytic anemia and thrombocytopenia, including thrombotic thrombocytopenic purpura (TTP). A deficiency in ADAMTS13 enzyme levels, along with an inhibitory antibody, is found in most patients with idiopathic TTP. Patients with human immunodeficiency virus (HIV) infection can have a TTP-like illness; however, it appears to have a different etiology. METHODS A retrospective review of patients who had an ADAMTS13 activity level performed from 2005 through 2007 was completed. Patients with a diagnosis of HIV infection with TMA were investigated. RESULTS Two patients were identified. Case 1: a 47-year-old man with HIV infection and a CD4 count <10/microL presented with altered mental status, pneumonia, acute renal failure, thrombocytopenia, and anemia. The ADAMTS13 level was 71%. He was treated with plasma infusion. Two days after admission, he expired because of respiratory distress syndrome and metabolic lactic acidosis. Case 2: a 39-year-old man with HIV infection and a CD4 count of 9/microL presented with chest pain, acute renal failure, thrombocytopenia, and anemia. The ADAMTS13 level was 65%. He received multiple units of fresh frozen plasma without significant improvement in his platelet count. Six days after admission, the patient began highly active antiretroviral therapy, which resulted in a rapid increase in his platelet count. CONCLUSIONS HIV-associated TMA is postulated to have a different pathophysiology than idiopathic TTP. This study supports that assumption because both patients exhibited many of the classic findings of TTP but did not have a deficiency of ADAMTS13.
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Affiliation(s)
- Yara A Park
- Department of Pathology and Laboratory Medicine, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA.
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35
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Brecher ME, Hay SN, Park YA. Is it HIV TTP or HIV-associated thrombotic microangiopathy? J Clin Apher 2009; 23:186-90. [PMID: 18973113 DOI: 10.1002/jca.20176] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Thrombocytopenia is a common complication of Human Immunodeficiency Virus (HIV) infection. With advanced HIV disease, the presence of both thrombocytopenia and schistocytosis are frequently observed. In such cases, the diagnosis of HIV associated TTP is often considered. This article reviews emerging concepts of HIV associated microangiopathies. It concludes that the pathophysiology, in many cases seems to be distinct from idiopathic TTP (particularly with advanced HIV disease-<100 CD4/microliter). A sine que non for successful therapy of HIV-TMA appears to be the treatment of the underlying HIV infection.
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Affiliation(s)
- Mark E Brecher
- Department of Pathology and Laboratory Medicine, University of North Carolina Hospitals, Chapel Hill, North Carolina 27514, USA.
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36
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Malak S, Wolf M, Millot GA, Mariotte E, Veyradier A, Meynard JL, Korach JM, Malot S, Bussel A, Azoulay E, Boulanger E, Galicier L, Devaux E, Eschwège V, Gallien S, Adrie C, Schlemmer B, Rondeau E, Coppo P. Human Immunodeficiency Virus-Associated Thrombotic Microangiopathies: Clinical Characteristics and Outcome According to ADAMTS13 Activity. Scand J Immunol 2008; 68:337-44. [DOI: 10.1111/j.1365-3083.2008.02143.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
The term thrombotic microangiopathy (TMA) encompasses a group of conditions that are defined by, or result from, a similar histopathological lesion. Hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), and several other conditions are associated with TMA. Distinguishing HUS from TTP is not always possible unless there are specific causes, such as Shiga toxin, Streptococcus pneumoniae, or a specific molecular defect such as factor H or ADAMTS13 deficiency. This review describes the forms of HUS/TTP that are not related to Shiga toxin, pneumococcal infection, genetic causes, or ADAMTS13 deficiency. Conditions include HUS/TTP associated with autoimmune disorders, human immunodeficiency virus (HIV) infection, transplantation, malignancy, and medications.
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Affiliation(s)
- Lawrence Copelovitch
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Bernard S. Kaplan
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
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38
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Gunther K, Garizio D, Nesara P. ADAMTS13 activity and the presence of acquired inhibitors in human immunodeficiency virus-related thrombotic thrombocytopenic purpura. Transfusion 2007; 47:1710-6. [PMID: 17725738 DOI: 10.1111/j.1537-2995.2007.01346.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Little is known about the pathophysiology of human immunodeficiency virus (HIV)-related thrombotic thrombocytopenic purpura (TTP). It is generally assumed that acquired ADAMTS13 deficiency is due to the presence of autoantibody inhibitors, but limited data are available regarding ADAMTS13 activity and inhibitors in such patients. STUDY DESIGN AND METHODS By use of a collagen-binding assay, ADAMTS13 activity was analyzed at presentation in 20 patients with HIV-related TTP. The presence of inhibitors in patients with reduced ADAMTS13 activity was assessed with mixing studies. The correlation between ADAMTS13 activity and inhibitors and other laboratory and clinical parameters was assessed. RESULTS The patients fell clearly into two groups with regard to ADAMTS13 activity. Six patients (30%) had activity within the normal range, whereas the remaining 14 patients had severely reduced levels. Of the patients with reduced activity, only 5 patients had a detectable inhibitor whereas 8 showed no evidence of an inhibitor. There was significant correlation between normal ADAMTS13 activity and lower CD4 counts (p = 0.049). von Willebrand factor (VWF) antigen levels were significantly higher in patients with reduced ADAMTS13 activity (p = 0.03). Low activity in the absence of a detectable inhibitor was associated with significantly higher D-dimer levels (p = 0.01) and worse clinical outcome. CONCLUSION The heterogeneity with regard to ADAMTS13 activity and the absence of inhibitors in the majority of patients indicate that other factors are important in the pathogenesis of HIV-related TTP. VWF release and localized coagulation activation due to direct viral or cytokine-mediated endothelial cell injury is likely to be playing a major role.
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Affiliation(s)
- Karen Gunther
- Department of Haematology and Molecular Medicine and the Epidemiology Data Center, University of the Witwatersrand, Johannesburg, South Africa.
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39
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de Silva TI, Post FA, Griffin MD, Dockrell DH. HIV-1 infection and the kidney: an evolving challenge in HIV medicine. Mayo Clin Proc 2007; 82:1103-16. [PMID: 17803878 DOI: 10.4065/82.9.1103] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
With the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections has declined substantially, and cardiovascular, liver, and renal diseases have emerged as major causes of morbidity and mortality in individuals with human immunodeficiency virus (HIV). Acute renal failure is common in HIV-infected patients and is associated with acute infection and medication-related nephrotoxicity. HIV-associated nephropathy is the most common cause of chronic kidney disease in HIV-positive African American populations and may respond to HAART. Other important HIV-associated renal diseases include HIV immune complex kidney diseases and thrombotic microangiopathy. The increasing importance of non-HIV-associated diseases, such as diabetes mellitus, hypertension, and vascular disease, to the burden of chronic kidney disease has been recognized, focusing attention on prevention and control of these diseases in HIV-positive individuals. HIV-positive individuals who experience progression to end-stage renal disease and who have undetectable HIV-1 viral loads while receiving HAART should be evaluated for renal transplant. Emerging evidence suggests that HIV-positive individuals may have graft and patient survival comparable to HIV-negative individuals. Several studies suggest that HIV-1 can potentially infect renal cells, and HIV transgenic mice have clarified the roles of a number of HIV proteins in the pathogenesis of HIV-associated renal disease. Host factors may modify disease expression at the level of cytokine networks and the renal microvasculature and contribute to the pathogenic effects of HIV-1 infection on the kidney.
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Affiliation(s)
- Thushan I de Silva
- Section of Infection, Inflammation and Immunity, University of Sheffield School of Medicine and Biomedical Sciences, L Floor, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK
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40
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Gunther K, Garizio D, Dhlamini B. The pathogenesis of HIV-related thrombotic thrombocytopaenic purpura – is it different? ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1751-2824.2006.00041.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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