warfarin and Purpura--Thrombotic-Thrombocytopenic

Topics: Adult; Cerebral Cortex; Female; Humans; Intracranial Embolism; Purpura, Thrombotic Thrombocytopenic; Stroke; Warfarin

Topics: Adult; Antibodies, Monoclonal, Murine-Derived; Anticoagulants; Cesarean Section; Combined Modality Therapy; Enoxaparin; Female; Hemorrhage; Heparin; Humans; Infant, Newborn; Interdisciplinary Communication; Laryngeal Edema; Methylprednisolone; Patient Care Team; Plasma Exchange; Pregnancy; Pregnancy Complications, Hematologic; Puerperal Disorders; Pulmonary Embolism; Purpura, Thrombotic Thrombocytopenic; Recurrence; Rituximab; Warfarin

Thrombotic thrombocytopenic purpura (TTP), a complex thrombotic microangiopathy, remains an evolving enigma. A 49-year-old African-American woman presented with acute left hemiplegia, an ischemic cerebrovascular accident involving the right middle cerebral artery. Sequential appearance of thrombocytopenia and evidence of microangiopathic haemolysis led to the diagnosis of acquired idiopathic autoimmune TTP. This was managed with plasma exchange (PEX) and steroids. Early haematologic relapse within a month was managed with the addition of rituximab attaining sustained remission. The patient presented 3 years later with acute confusion and expressive aphasia due to multiple infarcts involving the left parieto-occipital cortex. Transoesophageal echocardiography demonstrated a pedunculated 6 mm mitral valvular mass consistent with a papillary fibroelastoma. Anticoagulation was instituted and the patient was continued on therapeutic oral warfarin. A haematologic relapse of TTP eventually emerged and was managed with PEX, steroids and rituximab. This vignette demonstrates several dilemmas in the clinical presentation, diagnosis and management of TTP in current day practice. Rituximab has adjuvant benefits to PEX and is being investigated as potential first-line therapy. Monitoring ADAMTS13 activity and inhibitor titre, as in our case, prove to have prognostic significance. Cardiac fibroelastomas are rare benign cardiac tumours usually arising from valvular endocardium with thromboembolic potential. One of the proposed mechanisms of origin of these masses is organizing thrombi in the setting of endocardial injury and inflammation questioning a possible link to thrombotic microangiopathy. To the best of our knowledge, this is the first report of this unique coexistence.

Topics: ADAM Proteins; ADAMTS13 Protein; Antibodies, Monoclonal, Murine-Derived; Anticoagulants; Female; Fibroma; Heart Neoplasms; Hemiplegia; Humans; Middle Aged; Mitral Valve; Plasma Exchange; Purpura, Thrombotic Thrombocytopenic; Rituximab; Steroids; Warfarin

A 67-year-old woman was admitted to the hospital for lethargy, fever, hemolytic anemia, thrombocytopenia, and consciousness disturbance. Direct Coombs test was positive, and anti-cardiolipin beta2-glycoprotein I antibody was detected. She was diagnosed with antiphospholipid syndrome complicated with autoimmune hemolytic anemia (AIHA). She demonstrated variable consciousness disturbance, inability to distinguish right from left, dysgraphia and dyscalculia. Multiple cerebral infarctions, especially dominant cerebral hemisphere infarctions, were observed on magnetic resonance imaging. A ventilation-perfusion scan demonstrated the presence of a ventilation-perfusion mismatch in both lung fields, and multiple veinous embolisms in the right femoral, bilateral the great saphenous and popliteal veins. Therefore, pulmonary embolism and thrombophlebitis were diagnosed. Based on these findings, it was necessary to distinguish this diagnosis from thrombotic thrombocytopenic purpura (TTP). As ADAMTS-13 activity was within the normal range, TTP was denied. Thereafter, the patient was treated with 1 mg/kg of prednisolone for AIHA, 3 mg of warfarin, and 3500 units of low-molecular-weight heparin for thrombosis, and her condition improved.

Topics: ADAM Proteins; ADAMTS13 Protein; Aged; Anemia, Hemolytic, Autoimmune; Anticoagulants; Antiphospholipid Syndrome; Biomarkers; Diagnosis, Differential; Female; Heparin, Low-Molecular-Weight; Humans; Prednisolone; Purpura, Thrombotic Thrombocytopenic; Treatment Outcome; Warfarin

Topics: Anticoagulants; Carcinoma, Signet Ring Cell; Female; Gangrene; Heparin, Low-Molecular-Weight; Humans; Lower Extremity; Lymphatic Metastasis; Middle Aged; Necrosis; Neoplasms, Unknown Primary; Purpura, Thrombotic Thrombocytopenic; Skin; Venous Thrombosis; Warfarin

Topics: Adult; Behcet Syndrome; Colchicine; Drug Therapy, Combination; Female; Humans; Plasma Exchange; Prednisone; Purpura, Thrombotic Thrombocytopenic; Treatment Outcome; Warfarin

Topics: Adult; Aspirin; Dipyridamole; Drug Therapy, Combination; Female; Humans; Prednisolone; Purpura, Thrombotic Thrombocytopenic; Warfarin

Two patients with thrombotic thrombocytopenic purpura (TTP) have recovered completely after intensive plasmapheresis. The mechanisms responsible for the improvement in these instances are most likely related to the removal of an inciting or damaging agent. The possibility that this agent may be an immune complex is discussed. Plasmapheresis appears to be useful therapy for some patients with this syndrome.

Topics: Adult; Dexamethasone; Exchange Transfusion, Whole Blood; Female; Humans; Male; Myocardial Infarction; Plasmapheresis; Purpura, Thrombotic Thrombocytopenic; Warfarin