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Bains S, Patel K, Bath T, Singh P, Kaur R, Patel P, Jamali M, Ghaffari MAZ. A Case of Thrombotic Thrombocytopenic Purpura Possibly Induced by Graves' Disease. Cureus 2022; 14:e29961. [PMID: 36381849 PMCID: PMC9635859 DOI: 10.7759/cureus.29961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 06/16/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) has historically been diagnosed with a pentad of features, i.e., thrombocytopenia, micro-angiopathic hemolytic anemia (MAHA), fever, neurological abnormalities, and kidney failure. Traditionally, TTP cases have been described in healthy adults. However, their association with autoimmune diseases is now well documented in the literature. There is limited availability of literature on the association between TTP and Graves' disease (GD). Here, we report a case of an adult female, a known case of Graves' disease, who has now been diagnosed with an acquired case of TTP. The presence of MAHA associated with thrombocytopenia was considered a clinical diagnosis of TTP and the patient immediately underwent plasma exchange (PEX), which led to the resolution of complaints. Hyperthyroidism cases should be adequately followed up as clinical severity could lead to the emergence of TTP.
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Affiliation(s)
- Shifali Bains
- Internal Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Kriyesha Patel
- Medicine, M.P. Shah Government Medical College, Jamnagar, IND
| | - Taranjit Bath
- General Medicine, Punjab Institute of Medical Sciences, Calgary, CAN
| | - Pawanpreet Singh
- Internal Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, IND
| | - Ravanjit Kaur
- Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Parth Patel
- Medicine, Shri M.P. Shah Medical College, Jamnagar, IND
| | - Momal Jamali
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Hussain T, Kumar J, Singh SJ, Kumar A, Qayum I. Concurrent thrombotic thrombocytopenic purpura and Guillian Barre Syndrome post infectious diarrhea. Ann Med Surg (Lond) 2022; 80:104301. [PMID: 36045839 PMCID: PMC9422312 DOI: 10.1016/j.amsu.2022.104301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) characterized by microangiopathic hemolytic anemia, thrombocytopenia and signs of organ dysfunction, is due to either congenital or acquired deficiency of ADAMTS13 gene. Guillian Barre Syndrome (GBS) is a post infectious disorder, most commonly associated with C. jejuni infection. Both conditions have high mortality if untreated and have been reported with other comorbid conditions. We found only one case report of sequential TTP and GBS. However, we report the first case of concurrent TTP and GBS infection in a 22 years old female after bloody diarrhea, successfully managed by symptomatic treatment, sessions of plasmapheresis, and hemodialysis. TTP and GBS have both been associated with bacterial and viral infections, and antibodies formed against them may result in cross reactivity due to molecular mimicry. It is suggested although unproven that in such cases, patients likely developed cross-reactivity against both platelet and neurogenic glycoproteins (the linking antigen) following predisposing infection. TTP is due to deficiency of ADAMTS13, defined by microangiopathic hemolytic anemia, thrombocytopenia, and organ dysfunction. GBS is post-infectious disease, defined by progressive symmetric weakness of limbs, diminished or absent reflexes, and paresthesia. Both GBS and TTP have been reported with bacterial and viral infection including C. jejuni. In concurrent cases molecular mimicry and aberrant immune response is a plausible explanation. Such patients likely developed cross-reactivity against both platelet and neurogenic glycoproteins following an infection.
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Yeter V, Koçak N, Arslan MT, Kan EK. Blood Count-derived Immunoinflammatory Markers in Thyroidassociated Ophthalmopathy. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:198-206. [PMID: 34120418 PMCID: PMC8200596 DOI: 10.3341/kjo.2021.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/14/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To investigate the diagnostic and prognostic significance of the blood-count derived systemic immunoinflammatory parameters in patients with thyroid-associated ophthalmopathy (TAO). Methods In this retrospective case-control study, the blood-count parameters and neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio, and systemic immune-inflammatory index (SII), thyroid peroxidase antibody, and anti-thyroglobulin antibody were evaluated in 46 patients with TAO and 46 matched controls. The associations of the immunoinflammatory parameters with clinical outcomes were analyzed among TAO patients. Results Significant differences were found in NLR, PLR, SII, and lymphocyte count between the controls and the TAO group (p < 0.05 for all). In logistic regression analysis, these inflammatory parameters did not have any prognostic effect on the clinical outcomes of the TAO (p > 0.05 for all). The patients, who needed systemic treatment due to any ocular involvement of TAO during the follow-up period, had significantly lower platelet count (p = 0.001) and PLR (p = 0.02) at the time of initial diagnosis when compared to the no treatment-needed group of the TAO patients. The initial platelet count was significantly associated with the subsequent steroid need due to TAO during the follow-up period (β = −0.02, p = 0.03). Conclusions NLR, PLR, and SII may serve as potential inflammatory markers in the identification of the TAO, although they have no evident prognostic significance in TAO. However, the relatively lower platelet count at initial diagnosis may be associated with the need for systemic therapy during the follow-up in patients with TAO.
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Affiliation(s)
- Volkan Yeter
- Department of Ophthalmology, Ondokuz Mayıs University, Samsun, Turkey
| | - Nurullah Koçak
- Department of Ophthalmology, Ondokuz Mayıs University, Samsun, Turkey
| | | | - Elif Kiliç Kan
- Department of Endocrinology, Ondokuz Mayıs University, Samsun, Turkey
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Hou L, Du Y. Atypical hemolytic uremic syndrome precipitated by thyrotoxicosis: a case report. BMC Pediatr 2020; 20:169. [PMID: 32303208 PMCID: PMC7164337 DOI: 10.1186/s12887-020-02082-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background Autoimmune thyroid disease (AITD) has a complex pathogenesis and is associated with the development of autoimmunity against the thyroid. Graves’ disease and Hashimoto’s thyroiditis are the two main types of AITD, and they are characterized by thyrotoxicosis and hypothyroidism, respectively. Atypical hemolytic uremic syndrome (aHUS) is a rare disease, presenting with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. aHUS is caused by dysregulation of the alternative complement pathway, and its co-existence with AITD is rare. Case presentation We report the case of a 12-year-old girl with recent onset thyrotoxicosis. She was first treated with propylthiouracil for 2 months and then developed AITD presenting as abrupt-onset thrombocytopenia, acute kidney injury, and microangiopathic hemolytic anemia. Thyroid function tests favored hyperthyroidism, with increased free T4 and free T3 levels and a very low level of thyroid-stimulating hormone (TSH). We suspected aHUS, and the patient’s condition responded dramatically to therapeutic plasma exchange (TPE) with disease remission. She experienced recurrent aHUS after subsequently receiving methimazole for 1 month, and in the recurrent episode, her condition responded again to TPE and concomitant glucocorticoids. She achieved euthyroidism with thiamazole ointment treatment, without aHUS recurrence during the 6-month follow-up. Mycophenolate mofetil was administered to manage proteinuria after 3 months of treatment with the steroid and angiotensin-converting enzyme inhibitor. Conclusions The coexistence of aHUS and AITD in this case is likely more than coincidence, because both are autoimmune in origin. aHUS is associated with a high mortality without appropriate therapy, and treatment with TPE and adjunct immunosuppressants can be helpful.
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Affiliation(s)
- Ling Hou
- Pediatric Nephrology Department, Shengjing Hospital of China Medical University, No.36 Sanhao Street Heping District, Shenyang City, 110004, Liaoning Province, China
| | - Yue Du
- Pediatric Nephrology Department, Shengjing Hospital of China Medical University, No.36 Sanhao Street Heping District, Shenyang City, 110004, Liaoning Province, China.
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Zhang J, Baugh L, Guileyardo J, Roberts WC. Thrombotic thrombocytopenic purpura with Graves' disease during pregnancy. Proc (Bayl Univ Med Cent) 2020; 33:270-272. [PMID: 32313485 DOI: 10.1080/08998280.2020.1713029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022] Open
Abstract
Thrombotic thrombocytopenic purpura may be seen with several autoimmune disorders such as immune thrombocytopenia purpura, immune hemolytic anemia, and systemic lupus erythematosus, but it is rarely associated with Graves' disease. We report a patient with thrombotic thrombocytopenic purpura associated with Graves' disease.
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Affiliation(s)
- Junlin Zhang
- Department of Pathology, Baylor University Medical CenterDallasTexas
| | - Laura Baugh
- Department of Pathology, Baylor University Medical CenterDallasTexas
| | - Joseph Guileyardo
- Department of Pathology, Baylor University Medical CenterDallasTexas
| | - William C Roberts
- Department of Pathology, Baylor University Medical CenterDallasTexas.,Division of Cardiology, Department of Internal Medicine, Baylor University Medical CenterDallasTexas
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Chaughtai S, Khan I, Gupta V, Chaughtai Z, Ong R, Asif A, Hossain MA. Graves disease-induced thrombotic thrombocytopenic purpura: a case report. J Med Case Rep 2019; 13:377. [PMID: 31831041 PMCID: PMC6909611 DOI: 10.1186/s13256-019-2307-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura is an autoimmune disease that carries a high mortality. Very few case reports in the literature have described a relationship between Graves disease and thrombotic thrombocytopenic purpura. We present a case of a patient with Graves disease who was found to be biochemically and clinically hyperthyroid with concurrent thrombotic thrombocytopenic purpura. Case presentation Our patient was a 30-year-old African American woman with a history of hypertension and a family history of Graves disease who had recently been diagnosed with hyperthyroidism and placed on methimazole. She presented to our hospital with the complaints of progressive shortness of breath and dizziness. Her vital signs were stable. On further evaluation, she was diagnosed with thrombotic thrombocytopenic purpura, depending on clinical and laboratory results, and also was found to have highly elevated free T4 and suppressed thyroid-stimulating hormone. She received multiple sessions of plasmapheresis and ultimately had a total thyroidectomy. The patient’s hospital course was complicated by pneumonia and acute respiratory distress syndrome. Her platelets stabilized at approximately 50,000/μl, and her ADAMTS13 activity normalized despite multiple complications. The patient ultimately had a cardiac arrest with pulseless electrical activity and died despite multiple attempts at cardiopulmonary resuscitation. Conclusion Graves disease is an uncommon trigger for the development of thrombotic thrombocytopenic purpura, and very few cases have been reported thus far. Therefore, clinicians should be aware of this association in the appropriate clinical context to comprehensively monitor hyperthyroid patients during treatment.
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Affiliation(s)
- Saira Chaughtai
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Ijaz Khan
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Varsha Gupta
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Zeeshan Chaughtai
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Raquel Ong
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Arif Asif
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA
| | - Mohammad A Hossain
- Internal Medicine Residency Program, Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, 07753, USA.
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