Infection as a cause of early relapse in patients recovering from thrombotic thrombocytopenic purpura

Abstract

Thrombotic thrombocytopenic purpura (TTP) is a rare but severe disorder characterized by hemolytic anemia, thrombocytopenia, fever, renal failure, and neurologic manifestations. Plasma exchange is the most effective treatment for this condition reducing mortality from 90% in untreated patients to 10%. However, infections acquired during the course of therapy could lead to early relapse of TTP. In this case report, we report three patients with TTP who initially responded well to plasma exchange treatments but suffered early relapses following bacterial infections. All these patients achieved remission once appropriate antibiotic therapy was instituted although one patient eventually received four courses of rituximab. This report emphasizes the need to be vigilant for new infections especially urinary tract infections in TTP patients undergoing plasma exchange. Instituting appropriate antibiotic therapy once an infection is suspected may reduce the need for prolonged plasma exchange procedures and extended hospital stay.

High prevalence of infectious events in thrombotic thrombocytopenic purpura and genetic relationship with toll‐like receptor 9 polymorphisms: experience of the French Thrombotic Microangiopathies Reference Center

“…Therefore, infections should be accurately sought during TTP management, particularly in patients who experience exacerbations. In these patients, a diagnosis of infection should imply a prompt antibiotherapy to prevent further endothelial activation and disease worsening 28‐30. In this regard, further studies, using more sensitive and more rapid culture systems, would deserve evaluation to improve our knowledge about the microbial ecology of TTP patients, to introduce earlier an adapted antimicrobial therapy.…”

“…In these patients, a diagnosis of infection should imply a prompt antibiotherapy to prevent further endothelial activation and disease worsening. [28][29][30] In this regard, further studies, using more sensitive and more rapid culture systems, would deserve evaluation to improve our knowledge about the microbial ecology of TTP patients, to introduce earlier an adapted antimicrobial therapy. Moreover, infections were not overrepresented during treatment in patients who received steroids and/or rituximab, suggesting that these immunomodulatory agents can be used safely in this indication, with no significant infectious side effects.…”

Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story

“…In patients with autoimmune TTP, rituximab was first introduced at the acute phase, in the more severe cases [30,48], and in patients with an insufficient (or suboptimal) response to conventional, TPE-based, treatment. Many single cases [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67] and small series [48,[68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84], most often from patients with a refractory disease or experiencing multiple relapses, reported encouraging results (Table 1). TPE were continued daily and rituximab was administered immediately after a TPE (except in one study [71], in which TPE were suspended).…”

Thrombotic Thrombocytopenic Purpura: A Hematological Emergency

“…Infection.Numerous case reports exist describing patients presenting with both initial episodes and relapses of TTP likely triggered by infection, and numerous infectious agents have been implicated (27,28). A recent retrospective study at a single institution found that 69% of its patients presenting with a thrombotic microangiopathic anemia also had laboratory-confirmed or clinically suspected infection (29).…”