Hypertensive Emergency with Thrombotic Microangiopathy or TTP? A Case Series and Literature Review

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.

Identification of 8 Rare Deleterious Variants in ADAMTS13 by Next-generation Sequencing in a Chinese Population with Thrombotic Thrombocytopenic Purpura

OBJECTIVE

Thrombotic thrombocytopenic purpura (TTP) is a rare and fatal disease caused by a severe deficiency in the metalloprotease ADAMTS13 and is characterized by thrombotic microangiopathy. The present study aimed to investigate the genes and variants associated with TTP in a Chinese population.

METHODS

Target sequencing was performed on 220 genes related to complements, coagulation factors, platelets, fibrinolytic, endothelial, inflammatory, and anticoagulation systems in 207 TTP patients and 574 controls. Subsequently, logistic regression analysis was carried out to identify the TTP-associated genes based on the counts of rare deleterious variants in the region of a certain gene. Moreover, the associations between common variants and TTP were also investigated.

RESULTS

ADAMTS13 was the only TTP-associated gene (OR = 3.77; 95% CI: 1.82-7.81; P=3.6×10ȡ4) containing rare deleterious variants in TTP patients. Among these 8 variants, 5 novel rare variants that might contribute to TTP were identified, including rs200594025, rs782492477, c.T1928G (p.I643S), c.3336_3361del (p.Q1114Afs*20), and c.3469_3470del (p.A1158Sfs*17). No common variants associated with TTP were identified under the stringent criteria of correction for multiple testing.

CONCLUSION

ADAMTS13 is the primary gene related to TTP. The genetic variants associated with the occurrence of TTP were slightly different between the Chinese and European populations.

Sequential treatment of rituximab and belimumab in thrombotic thrombocytopenia purpura associated with systemic lupus erythematous: A respective case series and literature review

INTRODUCTION

Thrombotic thrombocytopenia purpura (TTP) associated with systemic lupus erythematous (SLE), features the appearance of inhibitory autoantibodies against ADAMTS13. Rituximab and belimumab (BEL), as both targeting B cells, seem to be an optimal therapy to induce clinical remission, prevent relapse of disease and contribute to glucocorticoid induction. However, the clinical outcome of SLE-TTP treated with sequential therapy between rituximab and BEL remain elusive.

CASE SERIES

We reported the clinical outcomes of 4 patients diagnosed with SLE-TTP who were administrated a combination of corticosteroids, plasma exchange, and rituximab at stage of induction. BEL was utilized to rapidly reduce the reliance on these agents and prevent relapse of TTP at maintenance stage. Ultimately, 4 patients fully recovered with a SLE Disease Activity Index score of 0 and reached the goal at dose of prednisolone <7.5 mg/d without relapse.

CONCLUSION

Sequential treatment of rituximab and BEL could be an encouraging approach in treatment of SLE-TTP and rapid glucocorticoid reduction.

OCCULT RECURRENT BREAST CANCER MASQUERADING AS THROMBOTIC THROMBOCYTOPENIC PURPURA

GATA3 immunohistochemistry stain of the bone marrow biopsy required to diagnose recurrent metastatic breast cancer.

Clinical relapse of immune-mediated thrombotic thrombocytopenic purpura following COVID-19 vaccination

De novo and relapsed immune-mediated thrombotic thrombocytopenic purpura (iTTP) have been documented to have occurred following severe acute respiratory syndrome coronavirus 2 (COVID-19) vaccination. Here, we present a case of a 28-year-old woman who received the tozinameran (BNT162b2, Pfizer-BioNtech) vaccine for COVID-19 and experienced an iTTP relapse during longitudinal follow-up. She received the vaccine 30 months after her initial diagnosis, while she was in clinical remission. She was not in complete ADAMTS-13 remission, as she had undetectable ADAMTS-13 activity during follow-up except for one isolated measurement of 48%. Shortly after vaccination, she developed complaints of bruising, petechiae, ataxia, and an episode of slurred speech. Laboratory testing demonstrated thrombocytopenia, schistocytes, and eventually undetectable ADAMTS-13 activity. She was successfully treated with caplacizumab, rituximab, and corticosteroids without plasma exchange. She achieved complete clinical and ADAMTS-13 remission after treatment. We recommend caution in the administration of COVID-19 vaccines for survivors of iTTP in remission with severely deficient ADAMTS-13 activity.

Autoimmune cytopenias and thrombotic thrombocytopenic purpura

The autoimmune cytopenias are a group of disorders resulting primarily from autoantibody-mediated destruction of blood cells, with variable clinical sequelae depending on the severity and lineage affected. Disease presentation ranges from an asymptomatic finding on a routine full blood count to an acutely unwell patient suffering the clinical consequences of severe anaemia, neutropenia or thrombocytopenia. The cytopenia may be primary or secondary to underlying infectious, immune or malignant processes. Thrombotic thrombocytopenic purpura (TTP) is a distinct, rare but potentially life-threatening entity that classically but not invariably presents with a pentad of acute onset haemolytic anaemia, thrombocytopenia, neurological symptoms, renal impairment and fevers. Autoimmune cytopenias have formed a recognised diagnostic entity for over 150 years yet continue to present a challenge in medical practice due to heterogeneity in clinical presentation and triggering factors, an incomplete understanding of underlying pathophysiology and a lack of evidence-based therapeutic approaches.

Gemcitabine and carfilzomib induced thrombotic microangiopathy: eculizumab as a life-saving treatment

Drug‐induced aHUS is rare; however, early diagnosis is vital to reduce morbidity and mortality. With confirmation of the diagnosis, eculizumab appears to be a viable treatment option to suppress the pro‐inflammatory surge. Furthermore, adverse side effects of medications such as carfilzomib and gemcitabine should be considered in the appropriate settings.

Severe Ehrlichia chaffeensis infection in a lung transplant recipient: a review of ehrlichiosis in the immunocompromised patient

We describe a case of human ehrlichiosis in a lung transplant recipient and review published reports on ehrlichiosis in immunocompromised patients. Despite early therapy with doxycycline, our patient had unusually severe illness with features of thrombotic thrombocytopenic purpura. Of 23 reported cases of ehrlichiosis in immunocompromised patients, organ failure occurred in all patients and 6 (25%) died.