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Bruns L, Völker L, Klamroth R, Kuhlmann MK, Jabs WJ. Concomitant presentation of thrombotic thrombocytopenic purpura, immune thrombocytopenia, and autoimmune hemolytic anemia in a patient with newly diagnosed systemic lupus erythematosus. Clin Nephrol Case Stud 2023; 11:147-153. [PMID: 38170038 PMCID: PMC10759207 DOI: 10.5414/cncs111193] [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: 05/04/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024] Open
Abstract
Thrombocytopenia is always of concern when encountered in emergency settings. We report a case of a 29-year-old women in whom a unique constellation of hematological disorders occurred. The patient had been diagnosed with idiopathic immune thrombocytopenia (ITP) in 2007, with a history of several thrombocytopenic flares. She now presented with homonymous hemianopia accompanied by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) and was soon after diagnosed with a posterior stroke. Symptoms were more reminiscent of acquired thrombotic thrombocytopenic purpura (aTTP) rather than ITP. Immediate treatment with plasma exchange and caplacizumab curtailed MAHA, and progressive ischemic disease was averted. ADAMTS-13 testing confirmed the diagnosis of immune-mediated aTTP. Repeated testing for ITP, however, also showed IgG-loaded thrombocytes with the former known anti-GPIIb/IIIa specificity. Furthermore, autoimmune hemolytic anemia (AIHA) could be detected by direct antiglobulin test showing IgG and complement loading of the patient's erythrocytes. The autoimmune background of all three entities suggested an underlying systemic disease. Indeed, systemic lupus erythematosus (SLE) serology was strongly positive allowing for the diagnosis of SLE. ITP and AIHA as well as aTTP can be secondary to SLE, but emergence of all three disorders has not been reported at the same time.
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Affiliation(s)
- Lina Bruns
- Department of Nephrology, Vivantes Clinic in Friedrichshain, Berlin
| | - Linus Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), University Hospital Cologne, Cologne, and
| | - Robert Klamroth
- Department of Angiology and Hemostaseology, Vivantes Clinic in Friedrichshain, Berlin, Germany
| | | | - Wolfram J. Jabs
- Department of Nephrology, Vivantes Clinic in Friedrichshain, Berlin
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Rana A, Ahlawat P, Upadhyay P, Gupta A, Bansal A. Dengue Infection Triggering Concurrent Thrombotic Thrombocytopenic Purpura in a Case of Chronic Idiopathic Thrombocytopenic Purpura. Cureus 2023; 15:e43684. [PMID: 37724240 PMCID: PMC10505267 DOI: 10.7759/cureus.43684] [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] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
We present a case report detailing the medical history of a 53-year-old female who had a well-established 10-year history of idiopathic thrombocytopenic purpura (ITP). The patient presented with fever and gum bleeding, prompting a series of laboratory investigations. These examinations revealed concurrent thrombocytopenia and hemolytic anemia, alongside a positive test result for serum dengue IgM antibodies. Initial treatment for the patient involved intravenous administration of glucocorticoids and intravenous immunoglobulin. Regrettably, this therapeutic intervention did not yield a favorable response. Subsequent clinical developments, including the onset of generalized tonic-clonic seizures, raised suspicions of thrombotic thrombocytopenic purpura (TTP). A notable diagnostic indicator was the elevated PLASMIC score (platelet count; combined hemolysis variable; absence of active cancer; absence of stem-cell or solid-organ transplant; mean corpuscular volume; international normalized ratio; creatinine), reinforcing the consideration of TTP. To confirm the diagnosis, ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin motifs 13) enzyme levels were assessed and found to be low. Consequently, the patient was diagnosed with TTP. Plasmapheresis was administered, resulting in a positive clinical response after two cycles. Notably, the patient experienced a resolution of thrombocytopenia and hemolytic anemia. Following successful treatment, the patient was discharged with a prescription for immunosuppressants. This case underscores the critical importance of including TTP as a potential differential diagnosis when encountering patients with chronic ITP. TTP is characterized by its acute and life-threatening nature, often deviating from the typical clinical presentation. The application of the PLASMIC score serves as a valuable tool in guiding decision-making processes when TTP is suspected.
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Affiliation(s)
- Akash Rana
- General Medicine, Government Medical College & Hospital, Chandigarh, Chandigarh, IND
| | - Prashant Ahlawat
- General Medicine, Government Medical College & Hospital, Chandigarh, Chandigarh, IND
| | - Prateek Upadhyay
- Anesthesiology, Government Medical College & Hospital, Chandigarh, Chandigarh, IND
| | - Akshita Gupta
- General Medicine, Government Medical College & Hospital, Chandigarh, Chandigarh, IND
| | - Aman Bansal
- General Medicine, Government Medical College & Hospital, Chandigarh, Chandigarh, IND
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Mocanu A, Bogos RA, Lazaruc TI, Cianga AL, Lupu VV, Ioniuc I, Alecsa M, Lupu A, Ivanov AV, Miron IC, Starcea IM. Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13071228. [PMID: 37046448 PMCID: PMC10093431 DOI: 10.3390/diagnostics13071228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.
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Affiliation(s)
- Adriana Mocanu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Roxana Alexandra Bogos
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Tudor Ilie Lazaruc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Lavinia Cianga
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Mirabela Alecsa
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ancuta Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrith Crenguta Miron
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
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Lin HC, Huang J, Huang J, Zhang LJ, Yin XW, Yang JC, Huang XY. Concurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura: a case report and review of the literature. J Med Case Rep 2023; 17:38. [PMID: 36750960 PMCID: PMC9905008 DOI: 10.1186/s13256-023-03762-y] [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: 09/15/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura are both causes of thrombocytopenia. Recognizing thrombotic thrombocytopenic purpura is crucial for subsequent treatment and prognosis. In clinical practice, corticosteroids and rituximab can be used to treat both immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura; plasma exchange therapy is the first-line treatment in thrombotic thrombocytopenic purpura, while corticosteroids are strongly recommended as first-line treatment in immune thrombocytopenic purpura. The differential diagnosis of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is essential in clinical practice. However, case reports have suggested that immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura can occur concurrently. CASE PRESENTATION We report the case of a 32-year-old Asian female without previous disease who presented with pancytopenia, concurrent with immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura. The morphology of the megakaryocytes in the bone marrow indicated immune-mediated thrombocytopenia. The patient received glucocorticoid treatment, and her platelet count increased; however, schistocytes remained high during the course of the therapy. Further investigations revealed ADAMTS13 activity deficiency and positive ADAMTS13 antibodies. The high titer of antinuclear antibody and positive anti-U1-ribonucleoprotein/Smith antibody indicated a potential autoimmune disease. However, the patient did not fulfill the current criteria for systemic lupus erythematosus or mixed connective tissue disease. The patient responded well to plasma exchange therapy, and her platelet count remained normal on further follow-up. CONCLUSIONS Concurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is rare, but clinicians should be aware of this entity to ensure prompt medical intervention. Most of the reported cases involve young women. Human immunodeficiency virus infection, pregnancy, and autoimmune disease are the most common underlying conditions.
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Affiliation(s)
- Hung-Chen Lin
- grid.440671.00000 0004 5373 5131Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jinxiang Huang
- grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jing Huang
- grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Division of Hematology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Jun Zhang
- grid.440671.00000 0004 5373 5131Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiao-Wu Yin
- grid.440671.00000 0004 5373 5131Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jian-Cheng Yang
- grid.440671.00000 0004 5373 5131Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiao-Yan Huang
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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Sudden Cardiac Death in a Patient with Thrombotic Thrombocytopenic Purpura: A Case Report. Hematol Rep 2022; 14:203-209. [PMID: 35735738 PMCID: PMC9222959 DOI: 10.3390/hematolrep14020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/11/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
A 49-year-old female was admitted to our hospital with malaise and gross hematuria. As ADAMTS13 (a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13) activity was absent and the ADAMTS13 inhibitor was detected, she was diagnosed with acquired thrombotic thrombocytopenic purpura (TTP). In addition to plasma exchange and corticosteroid therapy, she received rituximab therapy for inhibitor boosting but died suddenly of a cardiac arrest on day 9. The postmortem revealed microvascular platelet thrombi in multiple organs. In this case, the deterioration of the patient’s clinical status was considered to have been caused by inhibitor boosting-induced systemic microvascular occlusion. In particular, her sudden death may have been due to cardiovascular microthrombosis. Since inhibitor boosting can cause TTP patients to deteriorate rapidly, it is crucial to manage TTP patients who undergo inhibitor boosting appropriately. The monitoring of cardiac complications in TTP patients may also be essential, especially in the acute phase.
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