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Mohamed KH, Shiza ST, Samreen I, Agboola AA, Mohamed AS, Kalluru PKR, Haseeb M, Munawar RZ, Nasir H. Non-ST-Segment Elevation Myocardial Infarction As Initial Thrombotic Event of Thrombotic Thrombocytopenic Purpura: A Rare Challenging Case. Cureus 2023; 15:e36363. [PMID: 37082484 PMCID: PMC10112854 DOI: 10.7759/cureus.36363] [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: 03/18/2023] [Indexed: 04/22/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare autoimmune and devastating blood disorder that results in micro-clots throughout the body, leading to tissue damage and organ dysfunction resulting in widespread microangiopathic hemolytic anemia, thrombocytopenia, fever, and neurological symptoms. TTP patients commonly manifest renal and neurological symptoms; however, cardiovascular involvement is not widely reported in the literature. We report a case of non-ST-segment elevation myocardial infarction (NSTEMI) as an initial manifestation of TTP. Although rare, TTP complications must be considered among other possible causes of unexpected thrombocytopenia during acute phase treatment of acute coronary syndrome because of high morbidity and mortality.
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Affiliation(s)
- Khalid H Mohamed
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, GBR
| | - Saher T Shiza
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Iqra Samreen
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | | | | | | | - Muhammad Haseeb
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
- Internal Medicine, Mount Sinai Hospital, Brooklyn, USA
| | | | - Hira Nasir
- Internal Medicine, Mayo Hospital, Lahore, PAK
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Șalaru DL, Adam CA, Marcu DTM, Șimon IV, Macovei L, Ambrosie L, Chirita E, Sascau RA, Statescu C. Acute myocardial infarction and extensive systemic thrombosis in thrombotic thrombocytopenic purpura: A case report and review of literature. World J Clin Cases 2021; 9:8104-8113. [PMID: 34621868 PMCID: PMC8462192 DOI: 10.12998/wjcc.v9.i27.8104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/19/2021] [Accepted: 07/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy characterized by the pentad of hemolytic anemia, fever, thrombocytopenia, renal failure, and neurological dysfunction. The formation of microthrombi in the arterioles and capillaries of various organs is one of the main pathophysiological mechanisms. Clinical manifestations of cardiac involvement in TTP patients are variable. Acute myocardial infarction has been reported as a complication with TTP as the secondary thrombotic event. Its emergence as the initial thrombotic event is extremely rare.
CASE SUMMARY A 49-year-old previously healthy man was admitted for fever, typical angina chest pain 3 d prior to presentation, and newly onset left lower limb pain. The electrocardiogram illustrated ST-elevation acute myocardial infarction of the antero-lateral wall of the left ventricle. Transthoracic echocardiography depicted two large thrombi at the apex of the left ventricle and moderately reduced ejection fraction (40%). Venous Doppler ultrasound showed occlusion of the left popliteal artery. Laboratory tests showed severe thrombocytopenia, mild hemolytic anemia, elevated D-dimers, and high troponin and creatine kinase-MB. Abdominal computed tomography revealed other thrombotic sites (superior mesenteric artery, posterior aortic wall, spleen and renal infarction, and ileum necrosis). He was immediately started on steroids and addressed to surgery for acute abdominal pain. After an initial stabilization of the hematological deficit, he went into general surgery for resection of the necrotic ileum but died soon after the intervention due to multiple organ failure.
CONCLUSION Cardiac involvement in TTP patients is common, challenging and more often fatal, especially when other thrombotic complications coexist.
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Affiliation(s)
- Delia Lidia Șalaru
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
- Internal Medicine, University of Medicine and Pharmacy, ”Grigore T. Popa Iași, Romania,” Iasi 700115, Romania
| | - Cristina Andreea Adam
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
| | - Dragos Traian Marius Marcu
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
- Internal Medicine, University of Medicine and Pharmacy, ”Grigore T. Popa Iași, Romania,” Iasi 700115, Romania
| | | | - Liviu Macovei
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
- Internal Medicine, University of Medicine and Pharmacy, ”Grigore T. Popa Iași, Romania,” Iasi 700115, Romania
| | - Lucian Ambrosie
- General Surgery, ”Sf. Spiridon” Emergency Hospital Iasi, Iasi 700111, Romania
| | - Elena Chirita
- General Surgery, ”Sf. Spiridon” Emergency Hospital Iasi, Iasi 700111, Romania
| | - Radu Andy Sascau
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
- Internal Medicine, University of Medicine and Pharmacy, ”Grigore T. Popa Iași, Romania,” Iasi 700115, Romania
| | - Cristian Statescu
- Department of Cardiology, Institute of Cardiovascular Diseases, “Prof. Dr. George I.M. Georgescu,” Iasi 700503, Romania
- Internal Medicine, University of Medicine and Pharmacy, ”Grigore T. Popa Iași, Romania,” Iasi 700115, Romania
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Tse B, Lim G, Sholzberg M, Pavenski K. Describing the point prevalence and characteristics of venous thromboembolism in patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2870-2877. [PMID: 33448602 DOI: 10.1111/jth.15027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Arterial thromboembolic events are relatively common and well-described in patients with thrombotic thrombocytopenic purpura (TTP). However, the literature describing venous thromboembolism (VTE) in TTP is scarce. METHODS Single-institution retrospective chart review was conducted in TTP patients over a 10-year period to describe the point prevalence of VTE. Data were analyzed using descriptive statistics. RESULTS We identified 77 consecutive patients with 123 episodes of TTP. Of these patients, 14 (18%) experienced 16 VTEs (6 pulmonary embolisms, 6 deep vein thromboses, 4 superficial vein thromboses [SVT]). Excluding SVT, the point prevalence of VTE was 14%. All were acute and associated with admission for acute TTP. All patients were treated with plasma exchange (PLEX); 6/8 patients on concurrent PLEX at VTE diagnosis were exchanged with solvent-detergent plasma (SDP). Platelet and lactate dehydrogenase levels at time of VTE diagnosis had largely normalized from presentation values (median 175 × 109 U/L [interquartile range 130.75, 250] and 232 U/L [interquartile range 178.75, 263.5], respectively). Most VTEs (9/16) occurred while patients were not on pharmacologic thromboprophylaxis. All but one VTE was treated with anticoagulation. No VTEs were fatal or massive. CONCLUSIONS Our data provide additional evidence that TTP patients may be at risk for VTE. It is possible that SDP exerted a prothrombotic effect. TTP-associated VTEs may be pathophysiologically distinct from arterial thromboses because they occur following hematological recovery. VTE thromboprophylaxis was not commonly used. Our findings suggest the need to implement VTE thromboprophylaxis earlier in hospitalized patients with TTP.
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Affiliation(s)
- Brandon Tse
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gloria Lim
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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