A Saudi multicenter experience on therapeutic plasma exchange for patients with thrombotic thrombocytopenic purpura: A call for national registry

BACKGROUND

The improvement in the clinical care for patients with thrombotic thrombocytopenic purpura (TTP) is evolving, and many efforts are being put to standardize it. Here, we aimed to assess the provided care at a national level and identify deficiencies.

METHODS

A national Saudi retrospective descriptive study was carried out at six tertiary referral centers and included all patients who underwent therapeutic plasma exchange (TPE) for the diagnosis of TTP between May 2005, and July 2022. Collected information included demographic data, clinical features on presentation, and the results of laboratory investigations at admission and discharge. In addition, the number of TPE sessions, days till the first session of TPE, usage of immunological agents, and clinical outcomes were all collected.

RESULTS

One hundred patients were enrolled, predominantly female (56%). The mean age was 36.8 years. At diagnosis, 53% of patients showed neurological involvement. The mean platelet count at presentation was 21 × 109 /L. All patients had anemia (mean hematocrit 24.2%). Schistocytes were present in the peripheral blood film of all patients. The mean number of TPE rounds was 13 ± 9.3, and the mean days to start TPE since admission for the first episode was 2.5 days. ADAMTS13 level was measured in 48% of patients and was significantly low in 77% of them. Assessing for clinical TTP scores, 83%, 1000%, 64% of eligible patients had an intermediate/high PLASMIC, FRENCH, and Bentley scores, respectively. Caplacizumab was used on only one patient, and rituximab was administered to 37% of patients. A complete response for the first episode was achieved in 78% of patients. The overall mortality rate was 25%. Neither time to TPE, the use of rituximab or steroid affected survival.

CONCLUSIONS

Our study shows an excellent response to TPE with a survival rate approximate to the reported international literature. We observed a deficiency in using validated scoring systems in addition to confirming the disease by ADAMTS13 testing. This emphasizes the need for a national registry to facilitate proper diagnosis and management of this rare disorder.

Blastocystis sp.-An emerging cause of diarrhea post stem cell transplantation

Key Clinical Message

Protozoans are endemic in the Middle East and diarrhea workup post stem cell transplant should always include stool examination for ova and parasites.

Abstract

We present a case of Blastocystis sp. infection in a multiple myeloma patient who developed diarrhea on day five of post-autologous stem cell transplantation. Diarrhea is a major complication and a potential cause of mortality in this population. Testing for endemic protozoan is recommended.

Medical management of early pregnancy failure with misoprostol with rupture of the cesarean section scar pregnancy

PURPOSE

To report a case of ruptured uterus in the first trimester with the use of misoprostol for early pregnancy tailure in a woman with unrecognized cesarean section scar pregnancy.

CASE

A 27-year-old woman, gravida 5 para 3+1, presented with abdominal pain and vaginal bleeding. Transvaginal ultrasonography revealed a fetus without fetal heart activity at nine weeks gestation, making the diagnosis of early pregnancy failure. Her previous deliveries were by cesarean section. She was managed medically with misoprostol. Seven hours after misoprostol administration, she developed sudden onset of severe abdominal pain. Repeat transvaginal ultrasonography diagnosed cesarean section scar pregnancy. Laparotomy revealed hemoperitoneum with rupture of cesarean section scar pregnancy. Subtotal hysterectomy was performed.

CONCLUSIONS

Failure to recognize cesarean section scar pregnancy can result in a ruptured uterus in the first trimester with the use of misoprostol for early pregnancy failure. Increased awareness of the unexpected consequences of cesarean section is of paramount importance.