Diclofenac-induced thrombotic thrombocytopenic purpura with concomitant complement dysregulation: a case report and review of the literature

Abstract

Background Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are two forms of thrombotic microangiopathies. They are characterized by severe thrombocytopenia, microangiopathic hemolysis, and thrombosis, leading to a systemic inflammatory response and organ failure. Plasmapheresis is used to treat thrombotic microangiopathies. A different entity known as atypical hemolytic uremic syndrome has garnered more clinical recognition because reported cases have described that it does not respond to standard plasmapheresis. Diclofenac potassium is a non-steroidal anti-inflammatory drug that is used to treat pain. Case report A 35-year-old Hispanic man presented to our emergency department with complaints of generalized malaise, fever, and an evanescent skin rash. During admission, he reported the use of diclofenac potassium for back pain on a daily basis for 1 week. He was noted to have peripheral eosinophilia, so he was admitted for suspected drug reaction involving eosinophilia and systemic symptoms. His initial laboratory work-up showed microangiopathic hemolytic anemia and thrombocytopenia. He also experienced a seizure, encephalopathy, and had a PLASMIC score of 7, thus raising concerns for thrombotic thrombocytopenic purpura. He underwent emergent plasmapheresis, which improved his clinical condition. The diagnosis was confirmed by assessing the levels of disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13, which was less than 3%. In addition, his skin biopsy was positive for patchy complement deposition, demonstrating complement dysregulation. Conclusion Thrombotic thrombocytopenic purpura is a rare condition that can be acquired. Our case is rare because it represents the first report of diclofenac potassium-induced thrombotic thrombocytopenic purpura with subjacent complement activation and dysregulation. Early recognition and aggressive management led to a favorable outcome.

A study of the regional differences in propacetamol-related adverse events using VigiBase data of the World Health Organization

“…Our findings support this hypothesis of heterogeneity as only seven AEs, among the top 20 frequently reported AEs, overlapped between Asia and Europe (Supplementary Material 3). Moreover, we found zero reports of propacetamol-associated thrombosis or contact dermatitis/eczema in Asia, which is line with previous studies as case reports were available only for thrombosis associated with non-selective NSAIDs [20][21][22][23][24] , and for contact dermatitis with NSAIDs (e.g., diclofenac, indomethacin, ibuprofen, and ketoprofen) [25][26][27] . Data on propacetamol or intravenous paracetamol were inconclusive to deduce any meaningful relations, although one study reported a relatively lower incidence of thrombosis among Asian and Pacific populations over other regions [28][29][30] .…”

Furosemide-Induced Thrombotic Thrombocytopenic Purpura: A Report of a Rare Case

“…It is characterized by microangiopathic hemolytic anemia and severe thrombocytopenia with or without damage to the kidney and other organs [6]. TTP caused by drugs such as mitomycin, ciprofloxacin, and diclofenac has been mentioned in the literature among other drugs [7][8][9].…”

Synthesis, characterization, and evaluation of biological activities of new 4′‐substituted ruthenium (II) terpyridine complexes: Prospective anti‐inflammatory properties

“…The standard drugs showed a high percentage of hemolysis of 54.5-58.0% and 47.92-92.45% for diclofenac potassium and ibuprofen, respectively, at a concentration of F I G U R E 2 TGA results of complexes 9, 10, and under N 2 atmosphere 250-500 μg ml −1 , which are in agreement with their reported toxicity criteria. [55][56][57] Therefore, these FDAapproved drugs are considered more toxic than the presently investigated compounds except for 9. These results indicate that all compounds except for 9 are safer than the standard drugs especially at low concentrations and can be examined for pharmacological purposes.…”