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Song Y, Lee SY, Chee YL, Jen WY. Hypertensive Emergency with Thrombotic Microangiopathy or TTP? A Case Series and Literature Review. J Clin Med 2024; 13:1880. [PMID: 38610645 PMCID: PMC11012678 DOI: 10.3390/jcm13071880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is associated with both hypertensive emergency and primary thrombocytopenia purpura (TTP). However, their clinical management is vastly different, with the latter necessitating urgent plasma exchange (PEX). We report two cases of hypertension-associated TMA (HTN-TMA) and a literature review of the clinical management of malignant hypertension. We suggest that in patients presenting with hypertensive emergency associated with TMA, a clinical diagnosis of HTN-TMA should be made, with emergent treatment to lower blood pressure started immediately. Although TTP is a differential diagnosis for TMA, PEX should not be started concurrently in the absence of other supporting evidence for TTP.
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Affiliation(s)
- Yang Song
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Shi Yan Lee
- Division of Gastroenterology & Hepatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
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2
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Dhar Chowdhury S, Thomas A, Kurien RT, Gupta P, John A, Rajeeb J, David VG, Nair SC, Simon EG, Dutta AK, Joseph AJ, Eapen CE. Secondary thrombotic microangiopathy (TMA) precipitated by acute pancreatitis: A case series. Pancreatology 2023; 23:1045-1047. [PMID: 38487925 DOI: 10.1016/j.pan.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/05/2023] [Accepted: 10/09/2023] [Indexed: 03/19/2024]
Affiliation(s)
| | - Ajith Thomas
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | | | - Piyush Gupta
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | - Anoop John
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | - Jaleel Rajeeb
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | | | - Sukesh Chandran Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India
| | - Ebby George Simon
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | - Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | | | - C E Eapen
- Department of Gastroenterology, Christian Medical College, Vellore, India
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Siniard RC, Gangaraju R, May JE, Marques MB. Challenges in the diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:861-869. [PMID: 37767808 DOI: 10.1080/17474086.2023.2265058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/26/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Immune-mediated TTP (iTTP) is a rare condition without pathognomonic signs and symptoms. For this reason, the diagnosis of iTTP may be delayed or even missed, with potentially catastrophic consequences. AREAS COVERED The authors performed an extensive literature review on the diagnosis of iTTP and its challenges combined with their own experience in a referral center for patients with iTTP. EXPERT OPINION Although a definitive diagnosis of iTTP depends on the ADAMTS13 activity result, timely testing is rarely available at many centers to which patients present. If less complex tests were to become available, they would decrease the chances of late and/or missed diagnoses of iTTP throughout the world. While clinical scores to estimate the likelihood of iTTP exist, they are not well known, and can be misleading if used in the wrong context. Furthermore, the three scoring systems (PLASMIC, Bentley, and French) only moderately correlate with each other, which further complicates the landscape. The existence of these scores and how they should be used in practice is but one opportunity that can be seized through more robust programs to educate nonspecialist clinicians on how to recognize and treat patients with iTTP.
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Affiliation(s)
- Rance C Siniard
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Radhika Gangaraju
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jori E May
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marisa B Marques
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Agyapong KO, Folson A, Wonkyi R, Amenyedor K, Boateng JJ, Fiador K. Recurrent stroke in an African female with idiopathic thrombotic thrombocytopenic purpura: A case report. Clin Case Rep 2023; 11:e6860. [PMID: 36694637 PMCID: PMC9842876 DOI: 10.1002/ccr3.6860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
We report on a young Ghanaian female who was diagnosed with thrombotic thrombocytopenic purpura (TTP) but had an ischemic stroke as the initial presentation. She was successfully treated with therapeutic plasma exchange. This case illustrates how TTP can masquerade as ischemic stroke and the application of PLASMIC score without ADAMTS-13 assay in risk prediction.
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Affiliation(s)
| | - Aba Folson
- School of MedicineUniversity of Health and Allied SciencesHoGhana
| | - Roland Wonkyi
- Department of Internal MedicineGreater Accra Regional HospitalRidge – AccraGhana
| | - Kelvin Amenyedor
- Department of Internal MedicineGreater Accra Regional HospitalRidge – AccraGhana
| | | | - Kate Fiador
- Department of HaematologyGreater Accra Regional HospitalRidge – AccraGhana
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5
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Martinelli AW, Dunn W, McClure ME, Walker I, Stewart A, Karia S, Preston SD, Thiru S, Torpey N, Ojha S, Symington E, Nathan JA. A Case of Thrombotic Microangiopathy and Acute Sarcoidosis. Chest 2022; 162:e245-e248. [PMID: 36344132 PMCID: PMC9752182 DOI: 10.1016/j.chest.2022.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022] Open
Abstract
Although sarcoidosis is an established cause of multiorgan dysfunction, acute presentation with thrombotic microangiopathy resulting in severe renal and hematological sequelae has not been reported. We describe the case of a patient presenting with hypercalcemia, pancreatitis, and acute renal failure, followed by microangiopathic hemolytic anemia. Although there were no significant respiratory symptoms, thoracic radiology and mediastinal lymph node biopsy results were in keeping with sarcoidosis as the underlying cause of this multisystem presentation. Corticosteroids were commenced with clinical and biochemical improvement. This novel case highlights the need to consider sarcoidosis as part of the differential diagnosis for unusual multiorgan presentations and for early multidisciplinary involvement in such cases to permit optimal treatment.
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Affiliation(s)
- Anthony W. Martinelli
- Department of Respiratory Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England,Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, England,CORRESPONDENCE TO: Anthony Martinelli, MB, BChir
| | - William Dunn
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Mark E. McClure
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Ieuan Walker
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Andrew Stewart
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Sumit Karia
- Department of Radiology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Stephen D. Preston
- Department of Histopathology, Royal Papworth Hospital, Cambridge, England
| | - Sathia Thiru
- Department of Histopathology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Nicholas Torpey
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Sanjay Ojha
- Department of Renal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - Emily Symington
- Department of Haematology, Addenbrooke’s Hospital, Hills Road, Cambridge, England
| | - James A. Nathan
- Department of Respiratory Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, England,Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, England
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Nasrollahi F, Eilbert W. Thrombotic microangiopathy presenting with stroke-like symptoms. Am J Emerg Med 2022; 55:229.e5-229.e6. [PMID: 35094883 DOI: 10.1016/j.ajem.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022] Open
Abstract
Thrombotic microangiopathies are a diverse group of clinical syndromes characterized by microangiographic hemolytic anemia, thrombocytopenia, and organ dysfunction. We report a unique case of thrombotic microangiopathy in an adult caused by vitamin B12 deficiency that presented with stroke-like symptoms.
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Affiliation(s)
- Farrah Nasrollahi
- Department of Emergency Medicine, University of Illinois at Chicago, College of Medicine, Room 469 COME, 1819 West Polk Street, Chicago, IL 60612, United States.
| | - Wesley Eilbert
- Department of Emergency Medicine, University of Illinois at Chicago, College of Medicine, Room 469 COME, 1819 West Polk Street, Chicago, IL 60612, United States.
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Abstract
Microangiopathic hemolytic anemia and thrombocytopenia (MAHA-T) is a rare complication of acute pancreatitis (AP). Treatment with therapeutic plasma exchange (TPE) is used at many centers. The natural history of this disease is not well understood. We report a case of acute pancreatitis induced MAHA-T with end organ dysfunction and a normal ADAMTS13 level. Following three TPEs, the patient's clinical status, blood counts and hemolytic markers stabilized. Improvement occurred even after TPE was discontinued. The optimal management of AP-induced MAHA-T is poorly understood. Many centres are reporting good outcomes with the early initiation of TPE. MAHA-T associated with acute pancreatitis is often treated with early initiation of TPE. However, the value of TPE in altering the natural history of the condition is not well understood. Further study is required to understand the role of ADAMTS13 testing to guide treatment, and the role of TPE in management.
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Affiliation(s)
- Kevin M Hill
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
| | - Danielle Moorman
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Jonathan Mack
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Carol Gonsalves
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Roy Khalife
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
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