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Papakonstantinou A, Kalmoukos P, Mpalaska A, Koravou EE, Gavriilaki E. ADAMTS13 in the New Era of TTP. Int J Mol Sci 2024; 25:8137. [PMID: 39125707 PMCID: PMC11312255 DOI: 10.3390/ijms25158137] [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] [Received: 06/15/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening, often immune-mediated disease that affects 2-13 persons per million per year. Hemolytic anemia, thrombocytopenia, and end-organ damage due to the formation of microthrombi are characteristic of TTP. ADAMTS13 is a disintegrin, metalloproteinase, cleaving protein of von Willebrand factor (VWF) that processes the VWF multimers to prevent them from interacting with platelets and, in turn, to microvascular thrombosis. Prompt diagnosis of TTP is critical yet challenging. Thrombotic microangiopathies have similar clinical presentation. Measurement of ADAMTS13 activity helps in the differential diagnosis. Less than 10% ADAMTS13 activity is indicative of TTP. Laboratory ADAMTS13 activity assays include incubating the test plasma with the substrate (full-length VWM multimers) and detection with direct or indirect measurement of the cleavage product. The purpose of this study is to examine the diagnostic potential, advantages, and weaknesses of the ADAMTS13 potency in TTP.
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Affiliation(s)
- Anna Papakonstantinou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Panagiotis Kalmoukos
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Aikaterini Mpalaska
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Evaggelia-Evdoxia Koravou
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
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Altaf F, Shrivastava S, Allena R, Kumar J, Khaja M. Uncommon Manifestation: Thrombotic Thrombocytopenic Purpura Presenting Solely as Petechial Rash. Cureus 2024; 16:e57994. [PMID: 38738084 PMCID: PMC11087214 DOI: 10.7759/cureus.57994] [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: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder typically presenting with a classic pentad of symptoms: thrombocytopenia, microangiopathic hemolytic anemia, neurological abnormalities, renal dysfunction, and fever. This report explores an unusual presentation of TTP in a 47-year-old female with a medical history of hypertension, hyperlipidemia, and chronic TTP, who exhibited only petechial rashes, generalized weakness, and headache. Notably, the petechial rash, a less common manifestation of TTP, became a pivotal clue for the diagnosis, underscoring the necessity for vigilance even when classic symptoms are absent. This case reinforces the imperative of a high suspicion index for TTP, especially in patients with thrombocytopenia and hemolytic anemia, irrespective of other traditional signs. Plasmapheresis remains the treatment cornerstone, removing autoantibodies and replenishing ADAMTS13, as evidenced by the patient's initial response. The administration of rituximab, targeting B cells to mitigate autoantibody production against ADAMTS13, featured prominently in her management, aligning with its recognized role in refractory or relapsing TTP cases. Despite an encouraging response to rituximab, a subsequent decline in platelet count indicated the unpredictable nature of TTP and the necessity for multi-pronged therapeutic strategies. The patient's medical background and persistently low ADAMTS13 levels hinted at a chronic relapsing trajectory associated with increased morbidity and mortality. This necessitates ongoing vigilance and treatment flexibility. Highlighting this atypical TTP presentation, the report calls for immediate, robust intervention, serving as a critical reminder of the heterogeneity of TTP manifestations and the complexities in its management, thereby contributing to broader clinical awareness and improved patient prognoses.
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Affiliation(s)
- Faryal Altaf
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York, USA
| | - Shitij Shrivastava
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York, USA
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rachana Allena
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York, USA
| | - Jai Kumar
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York, USA
| | - Misbahuddin Khaja
- Internal Medicine/Pulmonary Critical Care, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York, USA
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Wali JA, Quigley BM, Schaefer B. Successful Use of Bortezomib in an Adolescent with Refractory TTP. Case Rep Hematol 2023; 2023:8173903. [PMID: 38046988 PMCID: PMC10693465 DOI: 10.1155/2023/8173903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
With increasing early and upfront use of rituximab and caplacizumab in the modern management of immune-mediated thrombotic thrombocytopenic purpura (iTTP), the risk of refractory disease is expected to decline. However, despite the use of adequate initial therapy, a small subset of patients develop a refractory disease which is difficult to manage. Bortezomib has come to be known as a safe and effective treatment option for refractory iTTP, but its use in children is limited. Here, we describe the case of an adolescent patient with refractory iTTP who had a satisfactory and sustained response to the use of bortezomib.
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Affiliation(s)
- Junaid Ahmad Wali
- Department of Internal Medicine, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Brian M. Quigley
- Division of Behavioral Medicine, Department of Medicine, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Beverly Schaefer
- Department of Pediatrics, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Tavakoli Shiraji S, Rostami MR, Kamranzadeh Foumani H, Mousavi SA, Vaezi M, Rad S, Babakhani D, Barkhordar M, Bahri T, Janbabaei G, Malekmohammadi A, Mohammadi S, Mansouri V. Clinical Features and Risk Factors of Relapse and Mortality in Thrombotic Thrombocytopenic Purpura Patients: A Seven-Year Experience. Int J Hematol Oncol Stem Cell Res 2023; 17:156-166. [PMID: 37817970 PMCID: PMC10560647 DOI: 10.18502/ijhoscr.v17i3.13305] [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: 09/15/2022] [Accepted: 05/22/2023] [Indexed: 10/12/2023] Open
Abstract
Background: Thrombotic thrombocytopenic purpura (TTP) is associated with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis. No comprehensive report exists on clinical characteristics and risk factors of relapse and mortality in Iranian TTP patients. In this study, we aimed to report clinical features of Iranian TTP patients, to evaluate disease relapse and mortality rate and their associated risk factors. Materials and Methods: This study was a cohort study of patients diagnosed with microangiopathic hemolytic anemia admitted to the Shariati Hospital, Tehran, a referral center for TTP patients, from 2010 to 2017. Demographic, clinical, and laboratory data were recorded and patients were followed for 3 years regarding disease relapse and mortality. Results: 114 patients (80 females, 34 males) with a mean age of 39.3 ± 14.99 years were included. Hematologic and neurologic symptoms were the most common manifestations. Abnormal laboratory findings at the presentation included thrombocytopenia, anemia, and elevated LDH. All patients were treated with plasma exchange, and 75.5% of them had a response to treatment, while the 3-year relapse and mortality rate was 23.6 and 26.3%. Lower platelet count was a predictor of disease relapse. Age, hematological, or neurological initial presentation were associated with TTP mortality. Conclusion: Based on the largest study of TTP patients ever in Iran, the demographic and clinical characteristics of Iranian TTP patients are similar to other existing reports. Knowledge of the risk factors for TTP relapse and mortality could be useful to alert hematologists for prompt therapeutic actions when necessary.
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Affiliation(s)
- Sahar Tavakoli Shiraji
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Rostami
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Kamranzadeh Foumani
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Hematologic Malignancies Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seied Asadollah Mousavi
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroush Rad
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Davood Babakhani
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Barkhordar
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Tanaz Bahri
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghasem Janbabaei
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Hematologic Malignancies Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Malekmohammadi
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Mohammadi
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
- Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Mansouri
- Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Español I, Leal JD, Blanquer M, García-Candel F, Heredia A, Gómez-Espuch J, González C, Montserrat J, Díaz-Carrasco MS, Martínez A, Moraleda JM. N-Acetylcistein for thrombotic thrombocytopenic purpura: an observational case series study. Ann Hematol 2023:10.1007/s00277-023-05248-9. [PMID: 37171598 PMCID: PMC10176284 DOI: 10.1007/s00277-023-05248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder. N-Acetylcysteine (NAC) rapidly degrades ultra-large von Willebrand factor multimers by disrupting the disulfide bonds. We report a series of twelve consecutive patients diagnosed with acquired TTP successfully treated with high-dose NAC (150 mg/kg/day) in combination with plasma exchange and steroids. Eight patients also received rituximab. Two patients presented refractory TTP. All patients achieved a quick clinical response in a median time of 5.5 days after starting NAC and are alive after a median follow-up of 29 months. The treatment was feasible and well tolerated. These data provide further evidence of the potential benefit and safety of adding NAC to the standard of care.
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Affiliation(s)
- Ignacio Español
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain.
| | - Juan Diego Leal
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Miguel Blanquer
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Faustino García-Candel
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Angela Heredia
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Joaquín Gómez-Espuch
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Celia González
- Pharmacy Department, IMIB-Pascual Parrilla, University of Murcia, Murcia, Spain
| | - Jorge Montserrat
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | | | - Antonio Martínez
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - José M Moraleda
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
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