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Zhou R, Chen S, Luo Q, Zhang X, Li F, Huang W, Sheng Z. Case report: COVID-19-associated refractory thrombotic thrombocytopenic purpura complicated with Guillain-Barré syndrome. Front Neurol 2023; 14:1199889. [PMID: 37292131 PMCID: PMC10244661 DOI: 10.3389/fneur.2023.1199889] [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: 04/05/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP), a rare and lethal thrombotic microangiopathy, is an autoimmune disease that can be triggered by viral infections such as COVID-19. This condition is characterized by hemolytic microangiopathy, thrombocytopenia, and neurologic alterations, possibly accompanied by fever and renal damage. Moreover, more than 220 patients with Guillain-Barré syndrome (GBS) have been reported in association with the COVID-19 infection. In this report, we present a case of a patient who developed refractory TTP complicated by GBS following a SARS-CoV-2 infection. We aimed to highlight the importance of accurately diagnosing neurological complications associated with a COVID-19 infection and to demonstrate our strategies for treating a patient with COVID-19 infection-related refractory TTP complicated by GBS.
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Affiliation(s)
- Rui Zhou
- Department of Neurological Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Shenjian Chen
- Department of Neurological Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qinghua Luo
- The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xinyue Zhang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Fang Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wei Huang
- Department of Neurological Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhiyong Sheng
- Department of Neurological Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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2
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Yin J, Tian H, Kong DQ, Li Y, Gu CY, Wu DP, Yu ZQ. [A combined regimen based on bortezomib and glucocorticoids for 6 patients with recurrent/refractory immune thrombotic thrombocytopenic purpura]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:413-417. [PMID: 37550192 PMCID: PMC10440622 DOI: 10.3760/cma.j.issn.0253-2727.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Indexed: 08/09/2023]
Abstract
Objective: To observe the efficacy and adverse reactions of a combination therapy regimen based on bortezomib and glucocorticoids in recurrent/refractory immune thrombocytopenic purpura (iTTP) . Methods: Six patients with recurrent/refractory TTP were included and treated with a glucocorticoid and two courses of bortezomib-based regimen. The clinical remission status of patients, changes in ADAMTS13 activity/ADAMTS13 inhibitor, and the occurrence of treatment-related adverse reactions were observed. Results: Of the 6 patients, 2 were males and 4 were females, with a median age of 21.5 (18-68) years. Refractory TTP was found in 1 case and recurrent TTP in 5 cases. Glucocorticoids were administered with reference to prednisone at 1 mg·kg(-1)·d(-1), and gradually reduced in dosage after achieving clinical remission. Bortezomib is subcutaneously administered at 1.3 mg/m(2) on days 1, 4, 8, and 11 with a 28-day treatment course consisting of 2 courses. Six patients achieved clinical remission after receiving bortezomib as the main treatment. ADMATS13 activity returned to normal in all patients with TTP after treatment, and the ADAMTS13 inhibitor turned negative. Thrombocytopenia is the most common adverse reaction after treatment, with other adverse reactions, including peripheral neuritis and abdominal pain, but ultimately all patients returned to normal. In a median follow-up of 26 (9-41) months, 5 patients maintained sustained remission, and 1 patient relapsed after 16 months of bortezomib treatment. Conclusion: Combination therapy of bortezomib and glucocorticoids has a satisfactory therapeutic effect and controllable adverse reactions for recurrent/refractory iTTP.
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Affiliation(s)
- J Yin
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - H Tian
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D Q Kong
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Y Li
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - C Y Gu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D P Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Z Q Yu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
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Duerson WA, Lopes CE, Dumani DA. Self-limited thrombotic thrombocytopenic purpura. Blood Coagul Fibrinolysis 2023; 34:218-220. [PMID: 36728967 DOI: 10.1097/mbc.0000000000001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Our team is presenting a patient who is a 57-year -old woman with a past medical history of cerebral vascular accident. The patient presented to the emergency department with symptoms of fever, right upper quadrant pain, and emesis. Initial diagnostic studies revealed thrombocytopenia with acute kidney injury, fever, and leukocytosis. After initiation of treatment for sepsis, the patient developed a hemolytic anemia, which resolved with administration of methylprednisolone. Labs subsequently revealed ADAMTS-13 activity of 4% with positive inhibitor, which confirmed the diagnosis of thrombotic thrombocytopenic purpura (TTP) after the patient's discharge. On retrospective analysis, the case represents a unique and rapid clinical recovery from TTP without administration of therapeutic plasma exchange, rituximab, or caplacizumab.
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4
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Herfurth K, Ruhe J, Kentouche K, Günther A, Brämer D, Eckardt N, Busch M, Wolf G. [Refractory thrombotic thrombocytopenic purpura]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:1307-1311. [PMID: 36194294 PMCID: PMC9531628 DOI: 10.1007/s00108-022-01408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 10/31/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) remains a serious illness with potentially life-threatening complications. The following case of a TTP patient describes a serious relapse with exacerbation in spite of adequately initiated therapy and highlights the necessity of interdisciplinary expertise in the treatment of the disease.
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Affiliation(s)
- K Herfurth
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - J Ruhe
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - K Kentouche
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - A Günther
- Hans-Berger-Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - D Brämer
- Hans-Berger-Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - N Eckardt
- Institut für Interventionelle und Diagnostische Radiologie, Abt. Neuroradiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - M Busch
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - G Wolf
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
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Yin J, Tian H, Kong D, Li Y, Gu C, Wang Z, Wu D, Yu Z. Bortezomib, a promising alternative for patients with refractory or relapsed thrombotic thrombocytopenic purpura after rituximab treatment. Br J Haematol 2022; 199:619-622. [PMID: 36076349 DOI: 10.1111/bjh.18430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jie Yin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Hong Tian
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Danqing Kong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yun Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chengyuan Gu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Zhaoyue Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Ziqiang Yu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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Tiscia G, Sartori MT, Giuffrida G, Ostuni A, Cascavilla N, Nicolosi D, Battista C, Santeramo TM, Melillo L, Giordano G, Cappucci F, Fischetti L, Chinni E, Tarantini G, Cerbo A, Bertomoro A, Fabris F, Grandone E. Focus on Key Issues in Immune Thrombotic Thrombocytopenic Purpura: Italian Experience of Six Centers. J Clin Med 2021; 10:jcm10235702. [PMID: 34884404 PMCID: PMC8658151 DOI: 10.3390/jcm10235702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura is a rare and challenging hematological disease caused by the antibody anti-ADAMTS13. Though the mortality rate has decreased considerably in recent years, fatalities still remain unacceptable. This study aimed at further adding to the existing knowledge of this medical challenge. We enrolled 89 consecutive patients observed in six Italian centers (from 8 August 2013 to 28 May 2021) with a diagnosis of immune-mediated thrombotic thrombocytopenic purpura. Clinical information and blood parameters were collected for all patients. We describe clinical manifestations and laboratory data, possible risk factors and the therapeutic management of first episodes or relapses. A total of 74 first episodes and 19 relapses (median 3 years (interquartile range (IQR): 2-7)) were recorded. Seventy percent of patients enrolled at the first episode showed neurological signs and/or symptoms. All the patients enrolled at the first episode were treated with plasma exchange (median = 12; IQR: 8-19.5) and methylprednisolone (1 mg/kg/day). Rituximab (375 mg/m2 weekly for four weeks) and caplacizumab were given to 15 (20.2%) and 2 patients (2.6%), respectively. We observed an overall mortality of 5.4% in the follow-up (median 60 months; IQR: 36.0-103.5). All fatalities occurred after a diagnostic delay. Present data point to the importance of the early detection of factors mostly associated with poor outcomes. It is likely that use of caplacizumab could improve the prognosis in those patients.
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Affiliation(s)
- Giovanni Tiscia
- Thrombosis and Hemostasis Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (G.T.); (F.C.); (L.F.); (E.C.)
| | - Maria Teresa Sartori
- Department of Internal Medicine, University of Padua, 35100 Padua, Italy; (M.T.S.); (A.C.); (A.B.); (F.F.)
| | - Gaetano Giuffrida
- Hematology Division, Department of Clinical and Molecular Biomedicine, University of Catania, 95123 Catania, Italy; (G.G.); (D.N.)
| | - Angelo Ostuni
- Transfusion Medicine & Blood Bank, University-Hospital of Bari, 70124 Bari, Italy; (A.O.); (C.B.)
| | - Nicola Cascavilla
- Division of Hematology, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Daniela Nicolosi
- Hematology Division, Department of Clinical and Molecular Biomedicine, University of Catania, 95123 Catania, Italy; (G.G.); (D.N.)
| | - Cosima Battista
- Transfusion Medicine & Blood Bank, University-Hospital of Bari, 70124 Bari, Italy; (A.O.); (C.B.)
| | - Teresa Maria Santeramo
- Division of Hematology, “Monsignor Raffaele Dimiccoli” Hospital, 70051 Barletta, Italy; (T.M.S.); (G.T.)
| | - Lorella Melillo
- Division of Hematology, University-Hospital of Foggia, 71122 Foggia, Italy;
| | - Giulio Giordano
- Division of Hematology, “Cardarelli” Hospital, 86100 Campobasso, Italy;
| | - Filomena Cappucci
- Thrombosis and Hemostasis Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (G.T.); (F.C.); (L.F.); (E.C.)
| | - Lucia Fischetti
- Thrombosis and Hemostasis Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (G.T.); (F.C.); (L.F.); (E.C.)
| | - Elena Chinni
- Thrombosis and Hemostasis Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (G.T.); (F.C.); (L.F.); (E.C.)
| | - Giuseppe Tarantini
- Division of Hematology, “Monsignor Raffaele Dimiccoli” Hospital, 70051 Barletta, Italy; (T.M.S.); (G.T.)
| | - Anna Cerbo
- Department of Internal Medicine, University of Padua, 35100 Padua, Italy; (M.T.S.); (A.C.); (A.B.); (F.F.)
| | - Antonella Bertomoro
- Department of Internal Medicine, University of Padua, 35100 Padua, Italy; (M.T.S.); (A.C.); (A.B.); (F.F.)
| | - Fabrizio Fabris
- Department of Internal Medicine, University of Padua, 35100 Padua, Italy; (M.T.S.); (A.C.); (A.B.); (F.F.)
| | - Elvira Grandone
- Thrombosis and Hemostasis Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (G.T.); (F.C.); (L.F.); (E.C.)
- Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, 119991 Moscow, Russia
- Department of Obstetrics and Gynecology, University of Foggia, 71122 Foggia, Italy
- Correspondence:
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Pavenski K, Huang SHS, Patriquin CJ. Predictors of relapse and preventative strategies in immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:1027-1040. [PMID: 34747320 DOI: 10.1080/17474086.2021.2003703] [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] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare autoimmune blood disorder, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis and is caused by severe deficiency of ADAMTS13. iTTP may result in both acute and chronic complications and is rapidly fatal without expedient treatment. Life-time risk of relapse is approximately 40%. AREAS COVERED A number of predictors of relapse has been described in the literature. The most well-studied predictor of relapse is persistent ADAMTS13 deficiency; however, it is not a perfect marker. Relapse can be prevented by treatment with immunosuppressive medications, with rituximab being the most studied. EXPERT OPINION Patients who recover from iTTP should be regularly assessed, including with ADAMTS13 activity testing. The optimal frequency of assessments has not been established, but every 3 months is recommended. Considering the potential for significant organ damage and mortality associated with iTTP relapse, patients in remission and with persistent ADAMTS13 activity of 10-20% should be prophylactically treated with immunosuppression. Additional markers to precisely identify patients at higher risk of relapse are needed.
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Affiliation(s)
- Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Shih-Han Susan Huang
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
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