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Hu L, Wang J, Jin X, Lu G, Fang M, Shen J, Tung TH, Shen B. Stress-induced hyperglycemia is associated with the mortality of thrombotic thrombocytopenic purpura patients. Diabetol Metab Syndr 2024; 16:44. [PMID: 38360738 PMCID: PMC10870494 DOI: 10.1186/s13098-024-01275-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with a rapid progression and high mortality rate. We aimed to explore early risk factors for mortality in patients with TTP. METHODS We conducted a retrospective analysis of 42 TTP patients that were admitted to our hospital between 2000 and 2021, with a median age of 49 (29-63) years. Risk factors for mortality were evaluated using multivariate logistic regression. Receiver operating characteristic curve analysis was used to determine the cut-off value of glucose for predicting mortality in patients, which was validated by comparison to a similar cohort in the published literature. RESULTS Elevated glucose level and reduced red blood cells (RBC) counts were risk factors for mortality in patients with TTP (glucose, odds ratio and 95% confidence interval: 2.476 [1.368-4.484]; RBC, odds ratio and 95% confidence interval: 0.095 [0.011-0.799]). The area under the curve of glucose was 0.827, and the cut-off value was 9.2 mmol/L, with a sensitivity of 75.0% and specificity of 95.8%. A total of 26 cases from the validation cohort had a sensitivity of 71.0% and a specificity of 84.0%. The change trends of the TTP-related laboratory indices differed during hospitalization. CONCLUSION Hyperglycemia at admission and unstable blood glucose levels during hospitalization may be potential predictors of mortality for TTP patients. The improved prognosis was associated with the recovery of platelet counts and a significant decrease in serum lactate dehydrogenase after five days of treatment.
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Affiliation(s)
- Lingling Hu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Jing Wang
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Xiaxia Jin
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Guoguang Lu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Meidan Fang
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Jian Shen
- Department of Hematology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China.
| | - Bo Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China.
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China.
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Wolkersdorfer AM, Jugovic I, Scheller L, Gutmann M, Hahn L, Diessner J, Lühmann T, Meinel L. PEGylation of Human Vascular Endothelial Growth Factor. ACS Biomater Sci Eng 2024; 10:149-155. [PMID: 37296497 DOI: 10.1021/acsbiomaterials.3c00253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Vascular endothelial growth factor A-165 (VEGF-A165) positively modulates neointimal hyperplasia, lumen stenosis, and neovascularization. One challenge for the use of VEGF-A165 for potential therapy is its short serum half-life. Therefore, we are designing VEGF-A165 bioconjugates carrying polyethylene glycol (PEG). The purity of the recombinantly expressed human VEGF-A165 exceeded 90%. The growth factor had a half-maximal effective concentration of 0.9 ng/mL (EC50) and induced tube formation of human umbilical vein endothelial cells. PEGylation was conducted by Schiff base reaction followed by reductive amination. After purification, two species were obtained, with one or two PEG attached per VEGF-A165 dimer. Both resulting bioconjugates had a purity exceeding 90%, wild-type bioactivity, and increased hydrodynamic radii as required for prolonging the half-life.
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Affiliation(s)
- Alena Maria Wolkersdorfer
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Isabelle Jugovic
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Lena Scheller
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Marcus Gutmann
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Lukas Hahn
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Joachim Diessner
- University of Würzburg, Department of Obstetrics and Gynecology, Josef-Schneider-Straße 14, Würzburg DE-97080, Germany
| | - Tessa Lühmann
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
| | - Lorenz Meinel
- Institute of Pharmacy and Food Chemistry, University of Würzburg, University, Am Hubland, Würzburg DE-97074, Germany
- Helmholtz Centre for Infection Research, Helmholtz-Institute for RNA-based Infection Research (HIRI), Josef-Schneider-Strasse 2/D15, Würzburg 97080, Germany
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Munjal RS, Sharma J, Polishetti S, Valleru PS, Banker H, Bandhu Gupta R, Anamika F, Jain R. Beyond Immunosuppression: The Intricate Relationship Between Tacrolimus and Microangiopathy. Cureus 2023; 15:e49351. [PMID: 38146570 PMCID: PMC10749684 DOI: 10.7759/cureus.49351] [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: 11/24/2023] [Indexed: 12/27/2023] Open
Abstract
Tacrolimus, widely known as Prograf, has become the preferred immunosuppressant for preventing graft rejection in solid organ transplant recipients, particularly in steroid-sparing regimens. Its efficacy and reduced risk of acute and chronic rejection compared to cyclosporine have made it the preferred treatment option for transplant patients. However, tacrolimus has drawbacks as it is associated with adverse effects, such as renal tubular necrosis, kidney failure, hypertension, metabolic acidosis, and new-onset diabetes mellitus. Among the less common but potentially severe complications is thrombotic microangiopathy linked to tacrolimus usage. Identifying and addressing this condition early on is crucial given its severity and potential complications. Manifestations of this microangiopathy can vary, encompassing renal, neurological, cardiac, and respiratory symptoms, and, in some cases, presenting as pancreatitis, intestinal ischemia, or skin abnormalities. Although conventional management often involves plasma exchange as the primary therapeutic option, recent insights into the pathophysiology have led to newer drugs, such as eculizumab and belatacept, offering promising outcomes. In this narrative review, we delve deeper into the underlying pathophysiological mechanisms of tacrolimus-induced thrombotic microangiopathy and aim to provide clinicians with valuable recommendations for efficient and timely treatment strategies. By understanding the complexities of this condition and staying abreast of the latest advancements in therapeutic options, healthcare providers can optimize patient outcomes and ensure safer tacrolimus administration in solid organ transplant recipients.
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Affiliation(s)
| | - Jagdish Sharma
- Internal Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | | | | | - Himanshi Banker
- Medicine and Surgery, Maulana Azad Medical College, Delhi, IND
| | | | - Fnu Anamika
- Medicine, University College of Medical Sciences, Delhi, IND
| | - Rohit Jain
- Internal Medicine, Penn State Health Hershey Medical Center, Hershey, USA
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4
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Plappert D, Kraft L, Amann K, Latus J. [Acute interstitial nephritis and hantavirus infection]. Dtsch Med Wochenschr 2023; 148:1525-1535. [PMID: 37949081 DOI: 10.1055/a-1950-7419] [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: 11/12/2023]
Abstract
Acute interstitial nephritis (AIN) is a cause of acute kidney injury and characterized by an inflammation of the tubulointerstitial space, leading to a decline in kidney function. Multiple etiologies can cause AIN including medications, autoimmune diseases and infections. A multiplicity of drugs is associated with AIN, while antibiotics (especially beta-lactams), proton-pump inhibitors (PPI) and non-steroidal anti-inflammatory agents (NSAIDs) are the most common. The pathognomonic triad of exanthema, fever and eosinophilia is rarely present in AIN patients. Treatment of medication-associated AIN is based upon the discontinuation of the provoking drug. Glucocorticoids can be considered in severe cases.Nephropathia epidemica (NE) is a disease caused by an infection with the Puumula-virus (PUUV) in northern and central Europe. Small rodents (mostly mice) are the host of the virus accountable for a rising number of infections during spring and summer. It is causing a syndrome consisting of AIN, fever and often thrombocytopenia. There is a good chance of complete recovery of kidney function following NE.
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Afrouzian M, Kozakowski N, Liapis H, Broecker V, Truong L, Avila-Casado C, Regele H, Seshan S, Ambruzs JM, Farris AB, Buob D, Chander PN, Cheraghvandi L, Clahsen-van Groningen MC, de Almeida Araujo S, Ertoy Baydar D, Formby M, Galesic Ljubanovic D, Herrera Hernandez L, Honsova E, Mohamed N, Ozluk Y, Rabant M, Royal V, Stevenson HL, Toniolo MF, Taheri D. Thrombotic Microangiopathy in the Renal Allograft: Results of the TMA Banff Working Group Consensus on Pathologic Diagnostic Criteria. Transpl Int 2023; 36:11590. [PMID: 37680648 PMCID: PMC10481335 DOI: 10.3389/ti.2023.11590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023]
Abstract
The Banff community summoned the TMA Banff Working Group to develop minimum diagnostic criteria (MDC) and recommendations for renal transplant TMA (Tx-TMA) diagnosis, which currently lacks standardized criteria. Using the Delphi method for consensus generation, 23 nephropathologists (panelists) with >3 years of diagnostic experience with Tx-TMA were asked to list light, immunofluorescence, and electron microscopic, clinical and laboratory criteria and differential diagnoses for Tx-TMA. Delphi was modified to include 2 validations rounds with histological evaluation of whole slide images of 37 transplant biopsies (28 TMA and 9 non-TMA). Starting with 338 criteria in R1, MDC were narrowed down to 24 in R8 generating 18 pathological, 2 clinical, 4 laboratory criteria, and 8 differential diagnoses. The panelists reached a good level of agreement (70%) on 76% of the validated cases. For the first time in Banff classification, Delphi was used to reach consensus on MDC for Tx-TMA. Phase I of the study (pathology phase) will be used as a model for Phase II (nephrology phase) for consensus regarding clinical and laboratory criteria. Eventually in Phase III (consensus of the consensus groups) and the final MDC for Tx-TMA will be reported to the transplantation community.
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Affiliation(s)
- Marjan Afrouzian
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | | | - Helen Liapis
- Department of Pathology and Immunology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Nephrology, Ludwig Maximilian University, Munich, Germany
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Luon Truong
- Department of Pathology, The Houston Methodist Hospital, Houston, TX, United States
| | - Carmen Avila-Casado
- Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Surya Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - David Buob
- Department of Pathology, Université de Sorbonne, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | | | - Lukman Cheraghvandi
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Stanley de Almeida Araujo
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Dilek Ertoy Baydar
- Department of Pathology, School of Medicine, Koç University, Sarıyer, Türkiye
| | - Mark Formby
- Department of Anatomical Pathology, NSW Health Pathology, Callaghan, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | | | | | - Eva Honsova
- AeskuLab Pathology and Department of Pathology, Charles University, Prague, Czechia
| | - Nasreen Mohamed
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Virginie Royal
- Department of Pathology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada
| | - Heather L Stevenson
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Maria Fernanda Toniolo
- Kidney Pancreas Transplantation, Instituto de Nefrología-Nephrology, Buenos Aires, Argentina
| | - Diana Taheri
- Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Pramanik D, Bhardwaj D, Karmani VK, Raval GG, Kutlar A. Successful Treatment of Refractory Thrombotic Thrombocytopenic Purpura (TTP) With Caplacizumab: A Case Report. Cureus 2023; 15:e42423. [PMID: 37637544 PMCID: PMC10448709 DOI: 10.7759/cureus.42423] [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: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
We report a female patient who presented with generalized weakness, episodes of altered mental status and slurred speech, and a history of systemic lupus erythematosus. Initial investigations showed profound thrombocytopenia and schistocytosis on peripheral blood smear. PLASMIC score was promptly calculated, and plasma exchange with steroids was initiated based on the initial high PLASMIC score. Bone marrow examination showed hypocellular marrow without any other obvious abnormalities. The patient's platelet counts initially improved but had a quick decline, on which, rituximab and subsequently caplacizumab were introduced. The patient was discharged after stabilization with plasma exchange (PLEX) therapy as needed on an outpatient basis.
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Affiliation(s)
| | | | - Vikash K Karmani
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Girindra G Raval
- Medicine: Hematology and Oncology, Medical College of Georgia at Augusta University, Augusta, USA
| | - Abdullah Kutlar
- Medicine: Hematology and Oncology, Medical College of Georgia at Augusta University, Augusta, USA
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Etiological diagnosis of post-diarrheal hemolytic uremic syndrome (HUS): humoral response contribution. Pediatr Nephrol 2023; 38:739-748. [PMID: 35802271 DOI: 10.1007/s00467-022-05671-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. HUS is classified according to its etiology as post-diarrheal or atypical HUS. Differential diagnosis of both entities continues to be a challenge for pediatric physicians. METHODS The aim was to improve the rapid etiological diagnosis of post-diarrheal HUS cases based on the detection of Shiga toxin (Stx)-producing Escherichia coli (STEC) infection by screening of stx1/stx2 and rfbO157 in cultured stools by multiplex PCR, and the additional detection of anti-lipopolysaccharide (anti-LPS) O157, O145, and O121 antibodies by Glyco-iELISA test. In addition, we studied patients' relatives to detect circulating pathogenic strains that could contribute to HUS diagnosis and/or lead to the implementation of measures to prevent dissemination of familial outbreaks. This study describes the diagnosis of 31 HUS patients admitted to Hospital Municipal de Niños Prof Dr Ramón Exeni during the 2017-2020 period. RESULTS Stool PCR confirmed the diagnosis of STEC associated with HUS in 38.7% of patients (12/31), while anti-LPS serology did in 88.9% (24/27). In those patients in which both methods were carried out (n = 27), a strong association between the results obtained was found. We found that 30.4% of HUS patients had at least one relative positive for STEC. CONCLUSIONS We could identify 96.3% (26/27) of HUS cases as secondary to STEC infections when both methods (genotyping and serology) were used. The results demonstrated a high circulation of STEC in HUS families and the prevalence of the STEC O157 serotype (83%) in our pediatric cohort. A higher-resolution version of the Graphical abstract is available as Supplementary information.
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8
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Gill R, Meghrajani V. Tacrolimus-Induced Thrombotic Microangiopathy After Orthotopic Heart Transplant: A Case Report. Cureus 2022; 14:e25874. [PMID: 35836452 PMCID: PMC9275527 DOI: 10.7759/cureus.25874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 11/24/2022] Open
Abstract
Tacrolimus (FK 506) is a calcineurin inhibitor and is commonly used as an immunosuppressant after a solid organ transplant. One of the serious adverse effects of tacrolimus is thrombotic microangiopathy (TMA) which has a high mortality rate. TMA leads to vascular thrombosis, eventually leading to ischemia of end organs. It is diagnosed clinically and based on the laboratory parameters. Early detection of TMA and prompt treatment can change the course. Drug-induced TMA has a poor prognosis as compared to idiopathic TMA. We present here the case of a 47-year-old male who developed tacrolimus-induced TMA after an orthotopic heart transplant and he was treated with the currently available treatment. He ultimately died after 40 days of hospitalization.
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Christiansen TK, Nilsson AC, Madsen GI, Voss A. Small intestine necrosis in catastrophic antiphospholipid syndrome: A rare and severe case. Lupus 2022; 31:754-758. [PMID: 35393873 DOI: 10.1177/09612033221093496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a multisystem autoimmune disease with widespread thrombotic events. In this case report, we present a young man with primary antiphospholipid syndrome (PAPS) admitted to the hospital with abdominal pain and vomiting. Abdominal computed tomography showed pneumoperitoneum and acute explorative laparotomy revealed small intestinal necrosis indicating small vessel thrombosis without involvement of large intestine. "Triple therapy" was initiated after surgery and the patient was treated in an intensive care unit for 72 days before being discharged to a rehabilitation clinic. A review of the literature regarding CAPS affecting small intestine shows it is extremely rare and may be associated with higher mortality.
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Affiliation(s)
| | | | - Gunvor I Madsen
- Department of Pathology, 74340Odense University Hospital, Odense, Denmark
| | - Anne Voss
- Department of Rheumatology, 74340Odense University Hospital, Odense, Denmark
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10
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Kell DB, Laubscher GJ, Pretorius E. A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications. Biochem J 2022; 479:537-559. [PMID: 35195253 PMCID: PMC8883497 DOI: 10.1042/bcj20220016] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 12/15/2022]
Abstract
Post-acute sequelae of COVID (PASC), usually referred to as 'Long COVID' (a phenotype of COVID-19), is a relatively frequent consequence of SARS-CoV-2 infection, in which symptoms such as breathlessness, fatigue, 'brain fog', tissue damage, inflammation, and coagulopathies (dysfunctions of the blood coagulation system) persist long after the initial infection. It bears similarities to other post-viral syndromes, and to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Many regulatory health bodies still do not recognize this syndrome as a separate disease entity, and refer to it under the broad terminology of 'COVID', although its demographics are quite different from those of acute COVID-19. A few years ago, we discovered that fibrinogen in blood can clot into an anomalous 'amyloid' form of fibrin that (like other β-rich amyloids and prions) is relatively resistant to proteolysis (fibrinolysis). The result, as is strongly manifested in platelet-poor plasma (PPP) of individuals with Long COVID, is extensive fibrin amyloid microclots that can persist, can entrap other proteins, and that may lead to the production of various autoantibodies. These microclots are more-or-less easily measured in PPP with the stain thioflavin T and a simple fluorescence microscope. Although the symptoms of Long COVID are multifarious, we here argue that the ability of these fibrin amyloid microclots (fibrinaloids) to block up capillaries, and thus to limit the passage of red blood cells and hence O2 exchange, can actually underpin the majority of these symptoms. Consistent with this, in a preliminary report, it has been shown that suitable and closely monitored 'triple' anticoagulant therapy that leads to the removal of the microclots also removes the other symptoms. Fibrin amyloid microclots represent a novel and potentially important target for both the understanding and treatment of Long COVID and related disorders.
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Affiliation(s)
- Douglas B. Kell
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, U.K
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kemitorvet 200, 2800 Kgs Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1 Matieland, 7602, South Africa
| | | | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1 Matieland, 7602, South Africa
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Smirnova TV, Kozlovskaya NL, Sheludchenko VM. [Ocular manifestations of primary thrombotic microangiopathy]. Vestn Oftalmol 2021; 137:138-144. [PMID: 34726868 DOI: 10.17116/oftalma2021137051138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article reviews literature on ocular manifestations of primary thrombotic microangiopathy. Thrombotic microangiopathy is a clinical and morphological syndrome that characterizes a systemic disseminated lesion of the microcirculatory bed, it is a special type of vascular damage that combines thrombosis and inflammation of the vascular wall leading to occlusion of the vessel lumen, causing ischemic damage to various organs and tissues. The classic types of primary thrombotic microangiopathy are thrombotic thrombocytopenic purpura, shigatoxin-associated hemolytic uremic syndrome (STEC-HUS) and atypical hemolytic uremic syndrome. Thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome are characterized by ischemic damage to the visual organ as a result of suspected thrombotic microangiopathy in the microcirculatory bed of the eye. The clinical picture of ocular manifestations of these diseases is similar, however the damage to the eye in the form of ischemic Purtscher-like retinopathy is more characteristic of atypical hemolytic uremic syndrome, which may be due to chronic uncontrolled activation of the alternative complement pathway in this disorder. Timely initiation of systemic therapy of the underlying disease in most cases leads to complete restoration of visual functions. A thorough ophthalmological examination of patients with these diseases is required.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
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12
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Gabr JB, Bilal H, Mirchia K, Perl A. The Use of Eculizumab in Tacrolimus-Induced Thrombotic Microangiopathy. J Investig Med High Impact Case Rep 2021; 8:2324709620947266. [PMID: 32757799 PMCID: PMC7412890 DOI: 10.1177/2324709620947266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) is a secondary cause of thrombotic microangiopathy and a potentially fatal inflammatory disease. DITMA has been attributed to a variety of drugs, particularly chemotherapeutic and immunosuppressive agents. Prompt diagnosis is critical for survival and treatment necessitates withdrawal of the offending drug; however, many cases require further treatment including plasmapheresis, immunosuppression, and anticoagulation. In this article, we report a cutaneous biopsy-proven case of tacrolimus-induced DITMA, which was successfully treated with eculizumab after failing the conventional standard of care.
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Affiliation(s)
| | - Hiba Bilal
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Andras Perl
- SUNY Upstate Medical University, Syracuse, NY, USA
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13
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Pieralli F, Milia A, Fruttuoso S, Bandini G, Mercatelli P, Nozzoli C, Luise F, Mancini A, Sammicheli L, Moggi Pignone A. The doctor who stared at schistocytes: an intriguing case of suspected thrombotic microangiopathic anemia. Intern Emerg Med 2021; 16:437-441. [PMID: 31667698 DOI: 10.1007/s11739-019-02219-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
A 33-year-old man with type 1 diabetes mellitus was admitted to the Internal Medicine Unit due to subacute onset of exertional dyspnea, with evidence at initial blood exams of severe macrocytic anemia with thrombocytopenia, biohumoral signs of hemolysis and 5 schistocytes per magnified field on the blood smear. A thrombotic microangiopathy (TMA) was suspected and plasma exchange (PEX) was started soon, since the risk of a life threatening condition. On the second day, after the results of A Disintegrin And Metalloproteinase with ThromboSpondin-1 motif, member 13 (ADAMTS-13) and reticulocytes were available, a critical reappraisal of the clinical scenario was done. B12 vitamin deficiency was evident after completing the diagnostic work-up. Finally, a diagnosis of "pseudo TMA vitamin B12 deficiency-related" was done. This is an intriguing and rare manifestation of cobalamin deficiency, given the very uncommon occurrence of schistocytes in this condition. "Pseudo TMA vitamin B12 deficiency-related" should be kept in mind when facing the differential diagnosis of microangiopathic anemia in the presence of a low proliferative index.
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Affiliation(s)
- Filippo Pieralli
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Alessandro Milia
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Silvia Fruttuoso
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Bandini
- Experimental and Clinical Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Paolo Mercatelli
- Experimental and Clinical Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Chiara Nozzoli
- Cell Therapy and Transfusion Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Fabio Luise
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Antonio Mancini
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lucia Sammicheli
- Intermediate Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alberto Moggi Pignone
- Experimental and Clinical Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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14
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Tripiciano C, Zangari P, Montanari M, Leone G, Massella L, Garaboldi L, Massoud M, Lancellotti S, Strocchio L, Manno EC, Palma P, Corsetti T, Luciani M. Case Report: Two Cases of Pediatric Thrombotic Thrombocytopenic Purpura Treated With Combined Therapy. Front Pediatr 2021; 9:743206. [PMID: 34796152 PMCID: PMC8593254 DOI: 10.3389/fped.2021.743206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/01/2021] [Indexed: 01/14/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy caused by a severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13. Over 95% of TTPs are acquired, due to autoantibody inhibitors. In children, acquired TTP is a very rare, life-threatening disease. To date, no consensus exists on the treatment strategy of pediatric TTP. We report the cases of two pediatric patients with a diagnosis of TTP, successfully treated with a combination of various therapeutic approaches. Although the patients complained of different sets of symptoms, laboratory data showed Coombs negative hemolytic anemia, renal impairment, and low platelet count in both cases. The diagnosis of acquired TTP was supported by the PLASMIC score and confirmed by the reduction of the ADAMTS13 activity and the presence of anti-ADAMTS13 antibodies. Intravenous immunoglobulin, corticosteroids, and plasma exchange (PEX) were performed without delay. As soon as available, caplacizumab was added to the therapy, with a prompt normalization of platelet count. Nevertheless, ADAMTS13 activity was persistently low, and anti-ADAMTS13 antibodies level was high; thus, a course of rituximab was administered, with persistent normalization of laboratory findings. No adverse events were observed during the treatment. In our experience, the combined use of PEX, caplacizumab, and immunosuppressive therapy during the acute phase of the disease is safe and may have a significant impact on the prognosis with successful clinical outcome and decrease in life-threatening events.
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Affiliation(s)
- Costanza Tripiciano
- Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Academic Department of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | - Paola Zangari
- Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mauro Montanari
- Unit of Transfusion Medicine, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giovanna Leone
- Unit of Transfusion Medicine, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Massella
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lucia Garaboldi
- Unit of Hospital Pharmacy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Michela Massoud
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefano Lancellotti
- Haemorrhagic and Thrombotic Diseases Service, Area of Hematology, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Rome, Italy
| | - Luisa Strocchio
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emma Concetta Manno
- Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Palma
- Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Tiziana Corsetti
- Unit of Hospital Pharmacy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matteo Luciani
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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15
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Sochat M, Hermelin D, Chakos D, Farooqui A, Lunt J, Vartanyan A, Poddar N. When the diagnosis is difficult to digest: severe vitamin B12 deficiency secondary to pernicious anemia mimicking life-threatening thrombotic thrombocytopenic purpura. J Hematop 2019. [DOI: 10.1007/s12308-019-00340-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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KOZLOVSKАYA NL, GАLSTYAN GM, STEPАNYUK VN. DIFFICULTIES IN DIAGNOSTICS OF ATYPICAL HEMOLYTIC UREMIC SYNDROME IN THE INTENSIVE CARE UNIT. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2019. [DOI: 10.21292/2078-5658-2019-16-4-65-76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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17
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Bommer M. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 155:608. [PMID: 30282578 PMCID: PMC6206392 DOI: 10.3238/arztebl.2018.0608b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Martin Bommer
- *Klinik für Hämatologie, Onkologie, Palliativmedizin und Infektionskrankheiten, Alb-Fils-Kliniken, Göppingen,
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18
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Hassenpflug WA, Schneppenheim R. Supplementary Therapeutic Recommendations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 155:608. [PMID: 30282577 PMCID: PMC6206398 DOI: 10.3238/arztebl.2018.0608a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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