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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Candar O, Ekinci O, Merter M, Aslan M, Aras I. Therapeutic plasma exchange in gastric signet ring cell carcinoma presenting as microangiopathic hemolytic anemia: A rare case report. J Clin Apher 2022; 37:606-610. [PMID: 36125111 DOI: 10.1002/jca.22013] [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: 06/02/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022]
Abstract
Microangiopathic hemolytic anemia (MAHA) defines a group of disorders characterized by the formation of microthrombi in capillaries and arterioles and the fragmentation of erythrocytes that pass through. Cancer-related MAHA is a rare but serious condition that is encountered in patients diagnosed with a malignancy. This clinical picture is thought to be linked to certain tumor characteristics; particularly, adenocarcinoma histology, vascular invasion, and bone marrow infiltration. MAHA is most commonly associated with tumors of gastric, prostate, and breast origin. The optimal treatment is not clear; however, there is evidence for the importance of promptly starting an effective antineoplastic regimen and it was also reported that administering therapeutic plasma exchange (TPE) therapy for immunocomplex removal could be beneficial for patients with symptoms of bleeding and thrombosis. Here, we present a case that presented a picture of MAHA secondary to gastric signet-ring cell adenocarcinoma (SRCC). The clinical picture was initially evaluated as thrombotic thrombocytopenic purpura and the patient benefited significantly from the TPE treatment administered before the adenocarcinoma diagnosis was confirmed. In this period, epistaxis stopped, platelet count increased from 25 × 109 /L to 162 × 109 /L, fragmented erythrocyte rate in the peripheral smear decreased by more than 75% and other laboratory findings of hemolysis (LDH, bilirubin, etc.) significantly improved.
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Affiliation(s)
- Omer Candar
- Department of Hematology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Omer Ekinci
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Mustafa Merter
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Mehmet Aslan
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Ibrahim Aras
- Department of Pathology, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
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3
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Lam R, Tarangelo N, Wang R, Horibe M, Grimshaw AA, Jain D, Haffar S, Bazerbachi F, Kunz PL, Li DK. Microangiopathic Hemolytic Anemia Is a Late and Fatal Complication of Gastric Signet Ring Cell Carcinoma: A Systematic Review and Case-Control Study. Oncologist 2022; 27:751-759. [PMID: 35589098 PMCID: PMC9438916 DOI: 10.1093/oncolo/oyac093] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Microangiopathic hemolytic anemia (MAHA) is a rare paraneoplastic syndrome that has been reported in patients with gastric signet ring cell carcinoma (SRCC). Clinical and prognostic features of MAHA in this setting have been poorly described. MATERIALS AND METHODS We conducted a systematic review in 8 databases of gastric SRCC complicated by MAHA and performed a case-control study assessing factors associated with survival in patients with gastric SRCC and MAHA in our pooled cohort compared with age-, sex-, and stage-matched cases of gastric SRCC from the Surveillance, Epidemiology, and End Results (SEER) database. Descriptive analyses were performed and multivariable Cox-proportional hazards regression modeling was used to determine factors associated with overall survival. RESULTS All identified patients (n = 47) were symptomatic at index presentation, commonly with back/bone pain, and dyspnea. Microangiopathic hemolytic anemia was the first manifestation of gastric SRCC in 94% of patients. Laboratory studies were notable for anemia (median 7.7 g/dL), thrombocytopenia (median 45.5 × 103/μL), and hyperbilirubinemia (median 2.3 mg/dL). All patients with MAHA had metastatic disease at presentation, most often to the bone, bone marrow, and lymph nodes. Median survival in patients with gastric SRCC and MAHA was significantly shorter than a matched SEER-derived cohort with metastatic gastric SRCC (7 weeks vs 28 weeks, P < .01). In multivariate analysis, patients with MAHA were at significantly increased risk of mortality (HR 3.28, 95% CI 2.11-5.12). CONCLUSION Microangiopathic hemolytic anemia is a rare, late-stage complication of metastatic gastric SRCC and is associated with significantly decreased survival compared with metastatic gastric SRCC alone.
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Affiliation(s)
- Robert Lam
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Nicholas Tarangelo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Rong Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT, USA
| | - Dhanpat Jain
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Samir Haffar
- Gastroenterology Department, Syrian Specialty Hospital, Damascus, Syrian Arab Republic
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, Saint Cloud Hospital, St. Cloud, MN, USA
| | - Pamela L Kunz
- Section of Medical Oncology, Department of Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Darrick K Li
- Corresponding author: Darrick K. Li, MD, PhD, P.O. Box 208019, New Haven, CT 06520-8019, USA. Tel: +1 203 785 7312; Fax: +1 203 785 7273;
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Maitta RW, Raval JS, Reeves HM, Fontaine MJ. Editorial: Thrombotic Microangiopathies, Diagnostic and Therapeutic Advances. Front Med (Lausanne) 2021; 8:778352. [PMID: 34912832 PMCID: PMC8667029 DOI: 10.3389/fmed.2021.778352] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert W Maitta
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM, United States
| | - Hollie M Reeves
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - Magali J Fontaine
- Department of Pathology, University of Maryland, Baltimore, MD, United States
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5
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Kim HJ, Yang JJ, Kim H, Hwang SH, Oh HB, Chung Y, Ko DH. Is Cryoprecipitate-Reduced Plasma an Efficacious Replacement Fluid for Therapeutic Plasma Exchange for Patients with Thrombotic Microangiopathy? A Single-Center Retrospective Experience. Lab Med 2021; 53:266-272. [PMID: 34791373 DOI: 10.1093/labmed/lmab092] [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] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We designed a study to compare the efficacy of cryoprecipitate-reduced plasma (CRP) and fresh frozen plasma (FFP), at the level of individual sessions, for treating refractory thrombotic microangiopathy (TMA) with therapeutic plasma exchange (TPE). MATERIALS AND METHODS Platelet counts (× 10³/μL) and lactate dehydrogenase (LD; IU/L) levels were measured before and after each session. We compared the mean-percentage and absolute changes in platelet count and LD after each TPE session. RESULTS The data from 33 patients treated for TMA between 2009 and 2018 were collected for this study. Both absolute and percentage increases in the platelet count were statistically significant (P = .003 and P = .011, respectively) when CRP was used. However, when patients were divided into subgroups according to specific diagnosis, no significant differences were found among the groups, except in terms of the absolute platelet count increase in the thrombotic thrombocytopenic purpura group (P <.001). CONCLUSION The platelet count increase was higher when patients received CRP than when they received FFP. We found that CRP may be a rescue option for patients with refractory TMA.
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Affiliation(s)
- Han Joo Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - John Jeongseok Yang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hyun Hwang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heung-Bum Oh
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yousun Chung
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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6
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Alhabhbeh A, Fatima Z, Thomas A, Cook C. Rare Presentation of Atypical Hemolytic Uremic Syndrome in an Adult. Cureus 2021; 13:e18184. [PMID: 34589371 PMCID: PMC8459801 DOI: 10.7759/cureus.18184] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 11/30/2022] Open
Abstract
Thrombotic microangiopathies (TMA) are disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia, and microthrombi leading to organ dysfunction. Atypical hemolytic uremic syndrome (aHUS) is a rare subtype of TMA mediated by complement dysregulation. We present a case of a 59-year-old female who presented with acute kidney injury and mild thrombocytopenia but with normal hemoglobin. We highlight the importance of prompt diagnosis of aHUS and initiating appropriate treatment with eculizumab.
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Affiliation(s)
- Ammar Alhabhbeh
- Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Zainab Fatima
- Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Akesh Thomas
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Christopher Cook
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
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7
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Long B, Bridwell RE, Manchanda S, Gottlieb M. Evaluation and Management of Thrombotic Thrombocytopenic Purpura in the Emergency Department. J Emerg Med 2021; 61:674-682. [PMID: 34518045 DOI: 10.1016/j.jemermed.2021.07.045] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a dangerous condition that can be misdiagnosed in the emergency department. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of TTP, with a focus on emergency clinicians. DISCUSSION TTP is a disorder with microangiopathic hemolytic anemia, severe thrombocytopenia, and multiorgan ischemic injury. It may be acquired or hereditary, and is caused by a reduced amount or function of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which is an enzyme involved in cleaving von Willebrand factor. The classic presentation of TTP includes fever, neurologic abnormalities, thrombocytopenia with purpura, microangiopathic hemolytic anemia, and acute renal injury. However, < 7% of cases have all of these findings present. Testing should include a complete blood count, complete metabolic panel, blood smear, coagulation panel, fibrinogen, D-dimer, lactate dehydrogenase, ADAMTS13 level, troponin, human immunodeficiency virus assessment, urinalysis, pregnancy test as appropriate, and electrocardiogram. Management includes hematology consultation if available, plasma exchange and corticosteroids, and treatment of end-organ complications. All patients require admission for treatment and close monitoring. CONCLUSION TTP is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Shivon Manchanda
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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8
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Jalali S, Jenneman D, Tandon A, Khong H. Thrombotic Microangiopathy: A Rare Breast Cancer-associated Complication Treated Successfully With Doxorubicin and Cyclophosphamide. In Vivo 2021; 35:1885-1888. [PMID: 33910877 DOI: 10.21873/invivo.12452] [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: 02/20/2021] [Revised: 03/09/2021] [Accepted: 03/19/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a clinical syndrome consisting of hemolytic anemia, thrombocytopenia, and presence of schistocytes on peripheral blood smear secondary to disorders of systemic microvascular thrombosis. Malignancy-associated TMA is a rare entity and shares clinical features with that of HUS and TTP usually seen in patients with metastatic cancer, tumor cell infiltration of the bone marrow and/or response to cancer-directed therapy. CASE REPORT We present a rare case of TMA secondary to breast cancer without evidence of bone marrow infiltration responsive to doxorubicin and cyclophosphamide treatment, after failed plasmapheresis with prednisone and later, eculizumab. CONCLUSION Despite being a rare manifestation of metastatic carcinoma, early identification and treatment are essential to improving survival.
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Affiliation(s)
- Samuel Jalali
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL, U.S.A.;
| | - Dakota Jenneman
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, U.S.A
| | - Ankita Tandon
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, U.S.A
| | - Hung Khong
- Department of Medical Oncology, Moffitt Cancer Center, Tampa, FL, U.S.A
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Witharana RA, Dissanayake A, Karunaratne I, Wijesinghe S. A Rare Case of Micro-Angiopathic Hemolytic Anemia Due to Envenoming by Giant Asian Honey Bee (Apis dorsata). Wilderness Environ Med 2021; 32:340-343. [PMID: 34030938 DOI: 10.1016/j.wem.2021.01.008] [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: 08/28/2020] [Revised: 01/10/2021] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
Giant Asian honey bee sting envenoming is a recognized cause of morbidity and mortality in rural Sri Lanka. Mass envenoming causes clinical effects, either as allergic and anaphylactic reactions or bee sting toxin-induced multiorgan damage. We report a patient who had mass envenoming from more than 1000 stingers who subsequently developed hematologic features suggestive of thrombotic microangiopathy-related hemolytic anemia. The transient acute kidney injury and acute hepatic failure seen in the patient were also considered to be secondary to thrombotic microangiopathy. A normal clotting profile and a high proportion of schistocytes in blood film ruled out disseminated intravascular coagulation as the underlying cause of the microangiopathic hemolytic anemia. The normal platelet count raised the possibility of a "partial" thrombotic microangiopathy, as has previously been reported in association with Shiga toxin-related hemolytic uremic syndrome and hump-nosed pit viper envenoming. Venom-induced direct toxicity on red cells was another possible explanation for the hemolysis, but the high proportion of schistocytes made it less likely. The place of therapeutic plasma exchange for venom-associated thrombotic microangiopathy is controversial. The patient recovered with symptomatic treatment and meticulous fluid management, without needing therapeutic plasma exchange as an adjunct treatment.
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Affiliation(s)
| | | | - Inoka Karunaratne
- Department of Zoology, University of Peradeniya, Peradeniya, Sri Lanka
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Talaie R, Shah S, Spano A, Shrestha P, Rosenberg M. Splenic Artery Embolization for Treatment of Iatrogenic Kasabach-Merritt Phenomenon Following Failed Endovascular Splenic Artery Aneurysm Repair. Vasc Endovascular Surg 2021; 55:741-743. [PMID: 33845690 DOI: 10.1177/15385744211003470] [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] [Indexed: 11/16/2022]
Abstract
Stent grafts are utilized to treat and exclude visceral arterial aneurysms while preserving flow through the vessel. Stent-associated thrombocytopenia is a rare complication not typically seen with modern stents. The following case describes the clinical presentation of stent kinking and consumptive coagulopathy. Stent-associated microangiopathic hemolytic anemia was inferred from protracted workup and exclusion of alternative diagnoses. Despite the risk of arterial puncture in the setting of profound thrombocytopenia, the patient was successfully treated with stent embolization with near immediate rebound in platelet count. This case report documents the presentation of rare stent-associated thrombocytopenia leading to challenging diagnostic evaluation and necessitating high-risk intervention.
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Affiliation(s)
- Reza Talaie
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, MN, USA
| | - Surbhi Shah
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, MN, USA
| | - Anthony Spano
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, MN, USA
| | - Prashant Shrestha
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, MN, USA
| | - Michael Rosenberg
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, MN, USA
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MacDougall KN, Schwartz B, Harewood J, Bukhari Z, Neculiseanu E. A Case of Gemcitabine-Induced Thrombotic Microangiopathy Treated With Ravulizumab in a Patient With Stage IV Pancreatic Cancer. Cureus 2021; 13:e13031. [PMID: 33680585 PMCID: PMC7931775 DOI: 10.7759/cureus.13031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 47-year-old male with stage IV pancreatic cancer developed gemcitabine-induced thrombotic microangiopathy (GiTMA) after treatment with gemcitabine and nab-paclitaxel. GiTMA is a rare and life-threatening complication with an incidence ranging from 0.015% to 1.4% and reported mortality rate ranging from 50% to 90%. Clinically, GiTMA manifests as microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Early identification of GiTMA is essential to initiate early treatment and improve survival. Treatment of GiTMA includes discontinuation of gemcitabine, along with initiation of steroids, therapeutic plasma exchange (TPE), rituximab, and eculizumab. To our knowledge, this is the first case of GiTMA treated with ravulizumab, a long-acting complement inhibitor. Given the increasing number of patients treated with gemcitabine and seriousness of this complication, it is important for physicians to be aware of this disease entity and maintain a high index of suspicion when evaluating patients with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure.
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Affiliation(s)
| | - Benjamin Schwartz
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Janine Harewood
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Zaheer Bukhari
- Pathology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Elvira Neculiseanu
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
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12
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Osman H, Alwasaidi TA, Al-Hebshi A, Almutairi N, Eltabbakh H. Vitamin B12 Deficiency Presenting With Microangiopathic Hemolytic Anemia. Cureus 2021; 13:e12600. [PMID: 33585090 PMCID: PMC7872473 DOI: 10.7759/cureus.12600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 12/11/2022] Open
Abstract
Vitamin B12 has essential roles in DNA synthesis, red blood cell development, and neurologic functions. Vitamin B12 deficiency is relatively common, particularly in people aged over 60 years. Among hematological disturbances, microangiopathic hemolytic anemia with thrombocytopenia or so-called pseudo-thrombotic microangiopathy (pseudo-TMA) is a particularly rare but significant clinical complication in patients with vitamin B12 deficiency. We herein describe a case of an elderly patient with pseudo-TMA whose lack of vitamin B12 was misdiagnosed as thrombotic thrombocytopenic purpura (TTP). The patient was admitted as a case of pancytopenia with a hemolytic picture. The initial impression was TTP versus acute promyelocytic leukemia M3. After examination of laboratory tests and bone marrow examination, we deduced that the patient had a B12 deficiency. The condition of the patient improved with B12 replacement. This report should remind physicians to widen their differential diagnoses when patients present with microangiopathic hemolysis or in patients who are not responsive to standard treatments for TTP.
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Affiliation(s)
- Haitham Osman
- Hematology, Prince Mohammed Bin Abdulaziz Hospital/Ministry of National Guard Health Affairs, Madinah, SAU
| | - Turki A Alwasaidi
- Hematology, Prince Mohammed Bin Abdulaziz Hospital/Ministry of National Guard Health Affairs, Madinah, SAU
- Internal Medicine, Taibah University, Madinah, SAU
| | - Abdulqader Al-Hebshi
- Pediatric Hematology Oncology, Prince Mohammed Bin Abdulaziz Hospital/Ministry of National Guard Health Affairs, Madinah, SAU
- Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Najah Almutairi
- Hematology, Prince Mohammed Bin Abdulaziz Hospital/Ministry of National Guard Health Affairs, Madinah, SAU
| | - Hussein Eltabbakh
- Internal Medicine, Prince Mohammed Bin Abdulaziz Hospital/Ministry of National Guard Health Affairs, Madinah, SAU
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13
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Gogia P, Gbujie E, Benge E, Bhasin S. Thrombotic Thrombocytopenic Purpura: Revisiting a Miss and an Inevitable Consequence. Cureus 2020; 12:e9283. [PMID: 32699732 PMCID: PMC7372183 DOI: 10.7759/cureus.9283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/19/2020] [Indexed: 12/15/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is typically characterized by the symptomatic pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, and renal failure. Atypical TTP is the diagnosis used to describe the subset of patients with TTP who present with symptoms that deviate from the classic pentad. We report a case an 86-year-old woman who presented to the emergency department complaining of chest pain for one day. She was reportedly on antibiotics for sinus infection. Physical examination revealed multiple bilateral superficial hematomas, predominantly on her extremities. On admission, her lab values were as follows: platelet count of 6,000/cubic millimeter, hemoglobin of 10.4 grams/deciliter, leukocyte count of 5100 cells/cubic millimeter, total bilirubin of 2.3 milligrams/deciliter, and troponin-I of 5.190 nanograms/milliliter. Peripheral blood smear was normal and did not reveal any schistocytes. The patient was admitted to the intensive care unit with a diagnosis of a non-ST-elevation myocardial infarction and a presumed diagnosis of immune thrombocytopenic purpura from antibiotic use. She was treated with intravenous solumedrol and a high-intensity statin. On the third day of her admission, the patient's mental functioning deteriorated and was intubated to protect her airway. A second peripheral smear revealed schistocytes, and subsequent laboratory studies supported the diagnosis of TTP. Plasma exchange therapy was planned. However, the patient succumbed to cardiac arrest before it could be initiated. The diagnosis was later confirmed with an ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) assay. This case serves as an example of one of the many ways in which TTP can present, and emphasizes the importance of considering TTP as a differential diagnosis.
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Affiliation(s)
- Pooja Gogia
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Ezioma Gbujie
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Elizabeth Benge
- Internal Medicine, St. George's University School of Medicine, Bethesda, USA
| | - Sidharth Bhasin
- Internal Medicine, Saint Peter's University Hospital/Rutgers University, New Brunswick, USA
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Kichloo A, Chugh SS, Gupta S, Pandav J, Chander P. Atypical Hemolytic Uremic Syndrome Presenting as Acute Heart Failure-A Rare Presentation: Diagnosis Supported by Skin Biopsy. J Investig Med High Impact Case Rep 2020; 7:2324709619842905. [PMID: 31010328 PMCID: PMC6480996 DOI: 10.1177/2324709619842905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder of uncontrolled complement activation that manifests classically as anemia, thrombocytopenia, and renal failure, although extrarenal manifestations are observed in 20% of the patient most of which involving central nervous system, with relatively rare involvement of the heart. In this article, we report the case of a 24-year-old male with no history of heart disease presenting with acute systolic heart failure along with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Given his presentation of thrombotic microangiopathy (TMA), along with laboratory results significant for low haptoglobin, platelets, hemoglobin, C3, C4, CH50, and normal ADAMTS13 levels, with no diarrhea and negative STEC polymerase chain reaction in stool, aHUS diagnosis was established with strong clinical suspicion, and immediate initiation of treatment was advised. Kidney biopsy to confirm diagnosis of aHUS was inadvisable because of thrombocytopenia, so the skin biopsy of a rash on his arm was done, which came to be consistent with thrombotic microangiopathy. Our case highlights a relatively rare association between aHUS and cardiac involvement, and the use of skin biopsy to support diagnosis of aHUS in patients who cannot undergo renal biopsy because of thrombocytopenia.
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Affiliation(s)
- Asim Kichloo
- 1 CMU Medical Education Partners, Saginaw, MI, USA
| | | | | | - Jay Pandav
- 2 Westchester Medical Center, Valhalla, NY, USA
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Buess CS, Germann AM, Maloney EP, Mohammed AB. Vitamin B12 Deficiency with Pseudothrombotic Microangiopathy and Thrombotic Thrombocytopenic Purpura: Similarities and Differences. Kans J Med 2020; 13:46-48. [PMID: 32190187 PMCID: PMC7053415] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/04/2019] [Indexed: 12/03/2022] Open
Affiliation(s)
- Charles Scott Buess
- University of Kansas School of Medicine-Wichita, Department of Internal Medicine, Wichita, KS
| | - Alexander M. Germann
- University of Kansas School of Medicine-Wichita, Department of Internal Medicine, Wichita, KS
| | - Eamon P. Maloney
- University of Nebraska Medical Center, Division of Internal Medicine, Omaha, NE
| | - Alaeldin B. Mohammed
- University of Kansas School of Medicine-Wichita, Department of Internal Medicine, Wichita, KS,Robert J. Dole VA Medical Center, Wichita, KS
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Abstract
We present a case of acute myeloid leukemia (AML) with myelodysplasia-related changes that presented as thrombotic thrombocytopenic purpura (TTP). Our patient presented with the classic pentad of TTP symptoms: anemia, thrombocytopenia, fever, elevated creatinine, and altered mental status. After a failure to respond to plasmapheresis therapy, we proceeded with a bone marrow biopsy and fluorescent in situ hybridization, which supported formal diagnosis of AML with myelodysplasia-related changes. Our case is an extremely rare presentation of a rare condition, as there have been no reported cases of AML with myelodysplasia-related changes presenting as TTP.
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Affiliation(s)
- Michael P Kucharik
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - David Waldburg
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Anitha Chandran
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Alison Kohn
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Roozbeh Nazarian
- Internal Medicine, Boca Raton Regional Hospital, Boca Raton, USA
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Kalambay J, Zaman R, Zaman M. Atypical Hemolytic Uremic Syndrome Presenting as Pre-eclampsia in a 24-year-old Woman with Chronic Kidney Disease: Pathogenesis and Genetics. Cureus 2018; 10:e3358. [PMID: 30510868 PMCID: PMC6257492 DOI: 10.7759/cureus.3358] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a kidney disorder that is frequently unrecognized during its progression, and misdiagnosed with more common etiologies of microangiopathic hemolytic anemia (MAHA): hemolytic uremic syndrome, disseminated intravascular coagulation, and thrombotic thrombocytopenic purpura (TTP). During pregnancy, the diagnosis of aHUS is furthermore challenging. The clinical presentation of aHUS may mimic pre-eclampsia as it occurred to the patient described in the case report. However, the persistence of thrombocytopenia in the patient after dilatation of the cervix and surgical evacuation of the contents of the uterus has led to consider aHUS. The pathogenesis of aHUS provides clues to understanding the insidious progression and the variability of clinical presentations of the disease. aHUS is primarily a kidney disorder that results from genetic defects of the alternative complement pathway (AP). Consequently, Eculizumab, a monoclonal antibody that targets the AP, induced remission in the patient. A single gene defect of the AP cannot cause the clinical manifestation of aHUS alone. Most of aHUS patients have a combination of mutation, haplotype, and single nucleotide polymorphism. Often, an identifiable environmental factor or a physiological change triggers the onset of the disease. We report the first case of aHUS in a pregnant woman with chronic kidney disease.
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Affiliation(s)
| | - Rehana Zaman
- Internal Medicine, Mount Sinai St. Lukes and West Hospital Center, New York, USA
| | - Mohammad Zaman
- Internal Medicine, Brookdale University Hospital, New York, USA
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18
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Abstract
The differential diagnosis of third trimester bleeding can range from placenta abruptia to placenta previa to uterine rupture and the placenta accreta spectrum (PAS). However, patients with risk factors such as multiple cesarean sections (c-sections), advanced maternal age (AMA), grand multiparity, and single-layer uterine closure are at greater risk of developing these complications earlier than we would traditionally expect. This case recounts a 38-year-old gravida 6 preterm 3 term 1 abortus 1 live 4 (G6P3114) at 23 weeks and five days gestational age (GA) with a past medical history of preterm pregnancy, pre-eclampsia, chronic abruptia, three previous c-sections, and low-lying placenta who presented to the emergency department (ED) with vaginal bleeding. Initial workup revealed placenta accreta and possible percreta. The patient was placed on intramuscular (IM) corticosteroids in anticipation of preterm delivery. As soon as the patient was stable, she was discharged home. She presented to a different hospital the next day with the same complaints. Imaging was consistent with accreta and her presentation with abruption. During the hospital stay, the patient went into threatened preterm labor (PTL). At first, we suspected preterm premature rupture of membranes (PPROM) due to apparent pooling of amniotic fluid in the vaginal canal. Upon further work up, the diagnosis was consistent with chronic abruption oligohydramnios sequence (CAOS). Before this could be investigated, her hospital course was complicated by acute abruption and Category III/nonreassuring fetal heart rate (FHR) tracing. The patient underwent an emergency c-section at 26 weeks GA as well as a planned supracervical hysterectomy for desired permanent sterilization. During the operation, the patient suffered a postpartum hemorrhage (PPH) of 4500 mL. She was later discharged home on postoperative day (POD) eight.
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Affiliation(s)
- Joshua A Ronen
- Internal Medicine, Texas Tech University Health Sciences Center of the Permian Basin, Odessa, USA
| | - Krystal Castaneda
- MS3/Ross University School of Medicine, California Hospital Medical Center, Los Angeles, USA
| | - Sara Y Sadre
- MS4/Ross University School of Medicine, California Hospital Medical Center, Los Angeles, USA
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Arya S, Bhargava V, Richardson J, Hawkins HK. Diffuse Chorangiomatosis as a Cause of Cardiomegaly, Microangiopathic Hemolytic Anemia and Thrombocytopenia in a Newborn. Fetal Pediatr Pathol 2017; 36:457-464. [PMID: 29227711 DOI: 10.1080/15513815.2017.1379041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The hallmark of diffuse chorangiomatosis is capillary dysvasculogenesis, diffusely involving the placenta. It can cause massive placental enlargement and may have adverse fetal effects. CASE REPORT A 32 weeks gestation male infant was born via cesarean section and had a placenta weighing 900 g. There was diffuse vascular proliferation involving the stem villi and intermediate villi. Short Nucleotide Polymorphism (SNP) microarray analysis of the placenta showed no biparental mosaicism or loss of heterozygosity, ruling out placental mesenchymal dysplasia. The infant also had cardiomegaly, microangiopathic hemolytic anemia and thrombocytopenia which spontaneously improved over time. CONCLUSION Diffuse chorangiomatosis can be associated with hemolysis, thrombocytopenia and cardiomegaly in the newborn. However, once delivered, these findings can spontaneously resolve over time.
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Affiliation(s)
- Shreyas Arya
- a Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , United States
| | - Vidit Bhargava
- b University of Texas Medical Branch at Galveston , Galveston , Texas , United States
| | - Joan Richardson
- b University of Texas Medical Branch at Galveston , Galveston , Texas , United States
| | - Hal K Hawkins
- b University of Texas Medical Branch at Galveston , Galveston , Texas , United States
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Chugh S, Kichloo A, Jafri F, Yusvirazi L, Lerner R. Multiple Myeloma as the Underlying Cause of Thrombotic Microangiopathy Leading to Acute Kidney Injury: Revisiting a Very Rare Entity. J Investig Med High Impact Case Rep 2017; 5:2324709617732797. [PMID: 28975130 PMCID: PMC5613796 DOI: 10.1177/2324709617732797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/28/2017] [Indexed: 11/17/2022] Open
Abstract
Thrombotic microangiopathy (TMA) describes a pathological process of microvascular thrombosis, consumptive thrombocytopenia, and microangiopathic hemolytic anemia, leading to end-organ ischemia and infarction, affecting particularly the kidney and brain. TMA is a pathological feature of a number of clinical disorders including thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and atypical hemolytic uremic syndrome. Rare but important, TMA may also occur in malignancy, connective tissue disease, malignant hypertension, and renal transplantation (rejection or drug toxicity). We present a very rare case where the patient developed acute kidney injury from TMA but found to have multiple myeloma as the possible underlying etiology.
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Affiliation(s)
| | - Asim Kichloo
- Central Michigan University, St Mary's Hospital, Saginaw, MI, USA
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Moreira DC, Ng CJ, Quinones R, Liang X, Chung DW, Di Paola J. Microangiopathic hemolytic anemia due to ADAMTS-13 loss in idiopathic systemic capillary leak syndrome. J Thromb Haemost 2016; 14:2353-2355. [PMID: 27622772 PMCID: PMC6553946 DOI: 10.1111/jth.13506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Indexed: 12/11/2022]
Abstract
Essentials Idiopathic systemic capillary leak syndrome (SCLS) is characterized by episodes of vascular leakage. We present the case of a patient with SCLS who developed microangiopathic hemolytic anemia (MAHA). We propose that this anemia is the result of ADAMTS-13 loss in the third-space fluid. This suggests that MAHA can occur in patients with significant extravasation of proteins. SUMMARY Idiopathic systemic capillary leak syndrome (SCLS) is a rare process characterized by acute and recurrent episodes of vascular leakage with severe hypotension, hypoalbuminemia, hemoconcentration and edema. Anemia and thrombocytopenia are not part of this syndrome, but here we present the case of a pediatric patient with a clinical presentation consistent with SCLS who subsequently developed microangiopathic hemolytic anemia at a time when she had significant fluid loss and anasarca. Based on serial ADAMTS-13 levels, we propose that the anemia in this patient developed as a result of ADAMTS-13 loss in the third-space fluid, a novel mechanism for acquired microangiopathic hemolytic anemia.
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Affiliation(s)
- D C Moreira
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - C J Ng
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - R Quinones
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
| | - X Liang
- Department of Pathology, University of Colorado, AMC, Aurora, CO, USA
| | - D W Chung
- Bloodworks Research Institute -Puget Sound, Seattle, WA, USA
| | - J Di Paola
- Department of Pediatrics, University of Colorado Anschutz Medical Campus (AMC), Aurora, CO, USA
- Human Medical Genetics and Genomics Program, University of Colorado, Aurora, CO, USA
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22
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Ostertag EM, Kacir S, Thiboutot M, Gulendran G, Zheng XL, Cines DB, Siegel DL. ADAMTS13 autoantibodies cloned from patients with acquired thrombotic thrombocytopenic purpura: 1. Structural and functional characterization in vitro. Transfusion 2016; 56:1763-74. [PMID: 27040144 PMCID: PMC4938786 DOI: 10.1111/trf.13584] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/25/2016] [Accepted: 02/06/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acquired thrombotic thrombocytopenia purpura (TTP) is a life-threatening illness caused by autoantibodies that decrease the activity of ADAMTS13, the von Willebrand factor-cleaving protease. Despite efficacy of plasma exchange, mortality remains high and relapse is common. Improved therapies may come from understanding the diversity of pathogenic autoantibodies on a molecular or genetic level. Cloning comprehensive repertoires of patient autoantibodies can provide the necessary tools for studying immunobiology of disease and developing animal models. STUDY DESIGN AND METHODS Anti-ADAMTS13 antibodies were cloned from four patients with acquired TTP using phage display and characterized with respect to genetic origin, inhibition of ADAMTS13 proteolytic activity, and epitope specificity. Anti-idiotypic antisera raised to a subset of autoantibodies enabled comparison of their relatedness to each other and to polyclonal immunoglobulin (Ig)G in patient plasma. RESULTS Fifty-one unique antibodies were isolated comprising epitope specificities resembling the diversity found in circulating patient IgG. Antibodies directed both to the amino terminal domains and to those requiring the ADAMTS13 cysteine-rich/spacer region for binding inhibited proteolytic activity, while those solely targeting carboxy-terminal domains were noninhibitory. Anti-idiotypic antisera raised to a subset of antibody clones crossreacted with and reduced the inhibitory activity of polyclonal IgG from a set of unrelated patients. CONCLUSIONS Anti-ADAMTS13 autoantibodies isolated by repertoire cloning display the diversity of epitope specificities found in patient plasma and provide tools for developing animal models of acquired TTP. Shared idiotypes of inhibitory clones with circulating IgG from multiple patients suggest common features of pathogenic autoantibodies that could be exploited for developing more targeted therapies.
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Affiliation(s)
- Eric M. Ostertag
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Stephen Kacir
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle Thiboutot
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Gayathri Gulendran
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - X. Long Zheng
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas B. Cines
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Don L. Siegel
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
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23
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Panchabhai TS, Patil PD, Riley EC, Mitchell CK. When the picture is fragmented: Vitamin B12 deficiency masquerading as thrombotic thrombocytopenic purpura. Int J Crit Illn Inj Sci 2016; 6:89-92. [PMID: 27308258 PMCID: PMC4901834 DOI: 10.4103/2229-5151.183026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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] [Indexed: 12/31/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) has high mortality and necessitates prompt recognition of microangiopathic hemolytic anemia (MAHA) and initiation of plasmapheresis. We present a challenging diagnostic workup and management of a 42-year-old man who presented with anemia, thrombocytopenia, and schistocytes on peripheral smear, all pointing to MAHA. Plasmapheresis and steroid therapy were promptly initiated, but hemolysis continued. Further workup showed megaloblastic anemia, severe Vitamin B12 deficiency, high iron saturation, and absent reticulocytosis, none of which could be explained by TTP. Severe Vitamin B12 deficiency can lead to hemolytic anemia from the destruction of red cells in the marrow that have failed the process of maturation. However, this should not cause thrombotic microangiopathy. Previous reports of B12 deficiency presenting with MAHA and a TTP-like manifestation have identified acute hyperhomocysteinemia as a missing link between B12 deficiency and MAHA, so this possibility was further explored. Our patient similarly had significantly elevated serum homocysteine levels, confirming this suspicion of Vitamin B12 deficiency. Vitamin B12 replacement led to normalization of the elevated levels of homocysteine, the disappearance of schistocytes on the peripheral smear, and resolution of the microangiopathic hemolysis, thereby confirming the diagnosis. It is pertinent that intensivists not only know the importance of early recognition and treatment of TTP but are also familiar with rare conditions that can present in a similar fashion.
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Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Pradnya D Patil
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth C Riley
- Department of Medicine, Division of Hematology-Oncology, James Graham Brown Cancer Center, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Charlene K Mitchell
- Department of Medicine, Division of General Internal Medicine, Palliative Medicine and Medical Education, School of Medicine, University of Louisville, Louisville, KY, USA
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Sharma D, Shastri S, Pandita A, Sharma P. Congenital thrombotic thrombocytopenic purpura: Upshaw-Schulman syndrome: a cause of neonatal death and review of literature. J Matern Fetal Neonatal Med 2015; 29:1977-9. [PMID: 26365135 DOI: 10.3109/14767058.2015.1071789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disorder in children characterized by microangiopathic hemolytic anemia (MAHA) and thrombocytopenia. The classic Moschcowitz Pentads of TTP include hemolytic anemia, with fragmentation of erythrocytes, thrombocytopenia, diffuse and non-focal neurologic findings, decrease renal function and fever. We report a newborn who was diagnosed with congenital TTP. The newborn was admitted at age of 40 h, in our hospital, in view of respiratory distress with impending respiratory failure and red colored urine. On examination, the newborn was febrile, tachypneic, had deep icterus, pallor and no hepatosplenomegaly. Family history was significant with one unexplained neonatal death at age of 24 with symptoms of red colored urine. Examination of peripheral smear was diagnostic with the presence of fragmented RBCS, giant but fewer platelets consistent with a diagnosis of MAHA. The diagnosis of TTP was confirmed with low ADAMTS activity and gene analysis showed c 2203 G > T-p.Glu735X (domain TSP1-2) mutation in exon 18 of ADAMTS 13 gene. The newborn had rapid deterioration, with respiratory distress and refractory shock leading to death. Post-mortem bone marrow done showed marrow hyperplasia.
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Affiliation(s)
- Deepak Sharma
- a Department of Pediatrics , Pt B.D Sharma PGIMS , Rohtak , Haryana , India
| | - Sweta Shastri
- b Department of Pathology , N.K.P Salve Medical College , Nagpur , Maharashtra , India
| | - Aakash Pandita
- c Department of Pediatrics , Government Medical College , Jammu , India , and
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Weintraub L, Ahluwalia M, Dogra S, Uehlinger J, Skversky A, Vasovic L. Management of streptococcal pneumoniae-induced hemolytic uremic syndrome: a case report. Clin Nephrol Case Stud 2014; 2:9-17. [PMID: 29043123 DOI: 10.5414/CNCS107887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 01/30/2014] [Indexed: 12/24/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) secondary to Streptococcus pneumoniae infections (pHUS) has been well reported in the literature and accounts for roughly 5% of all the cases of HUS. However, this condition is likely under-diagnosed and the incidence is believed to be increasing. Given this increase in incidence of pHUS, it is important to have an understanding of the optimal means to manage the disease. We report a case of a 2-year-old male with pneumonia, acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, diagnosed with pHUS and successfully treated with antibiotics, washed red blood cell (RBC) transfusions, plasma exchange (PE) with 5% albumin replacement, steroids, and hemodialysis. The response seen in our patient adds to the current literature and further supports the use of PE with albumin in patients with pHUS.
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26
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Huh HJ, Chung JW, Chae SL. Microscopic schistocyte determination according to International Council for Standardization in Hematology recommendations in various diseases. Int J Lab Hematol 2013; 35:542-7. [PMID: 23480787 DOI: 10.1111/ijlh.12059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [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: 09/04/2012] [Accepted: 01/21/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Recently, a consensus report for microscopic schistocyte determination was prepared by International Council for Standardization in Hematology (ICSH). ICSH focused on diagnosis of thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS). We aimed to reanalyze schistocytes according to ICSH recommendations, to study diseases other than TTP/HUS related to the schistocytes, and to compare the percentage of schistocytes among the various diseases. METHODS We retrieved all reported cases of peripheral blood (PB) smear in a single institution during 6 years. Schistocytes on 282 PB smears showing previous peripheral schistocytes and hemoglobin ≤10 g/dL were recounted according to ICSH recommendations. RESULTS The schistocytes were frequently observed in patients with microangiopathic hemolytic anemia (MAHA), metastatic carcinoma, sepsis, chronic renal failure, preterm infant, and infection. Only two among 34 patients categorized as MAHA were diagnosed as TTP/HUS. Schistocytes were observed with other morphological changes in 169 of 170 cases with schistocyte ≤1% and in 102 of 112 with schistocyte >1%. The median schistocyte percentages of patients with hematologic malignancy, megaloblastic anemia, acute renal failure, and preterm infant were 1.20%, 1.30%, 1.35%, and 1.70%, respectively. CONCLUSION Schistocytes were observed above 1% in many diseases other than TTP /HUS. Therefore, it is important to understand that schistocytes could be seen in various diseases, and in these cases, schistocytes were usually detected together with other red blood cell morphologic changes. These data support ICSH recommendation that a schistocyte count should be considered clinically meaningful if schistocytes represent the main morphological abnormality in the PB smear.
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Affiliation(s)
- H J Huh
- Department of Laboratory Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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27
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Abstract
Scorpion envenomations are a public health problem in many countries. Scorpions are second only to snakes in causing human fatalities from envenomation. Species of scorpions capable of inflicting fatal stings are living in North and South Africa, the Middle East, India, America, Trinidad, and Tobago. Hemiscorpius lepturus (from the Hemiscorpiidae family) is the most medically important scorpion in Iran which accounts for 92% of all hospitalized scorpion sting cases. The venom from H. lepturus is primarily a cytotoxic agent and has hemolytic, nephrotoxic, and to some extent, hepatotoxic activities. We found a combination of microangiopatic hemolytic anemia, thrombocytopenia, and acute renal failure in a seven year-old female child who was referred to us with a 12 h history of bloody urine following a H. lepturus sting. Her blood smear showed fragmented erythrocytes and burr cells, leading us to a diagnosis of hemolytic uremic syndrome (HUS). This report highlights the importance of acceptable prophylaxis and therapeutic protocols for HUS in these patients.
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Affiliation(s)
- E Valavi
- Department of Nephrology, Abuzar Pediatric Hospital, Ahwaz, Iran
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