Adenocarcinoma of the Lung Presenting as Thrombotic Thrombocytopenic Purpura

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Lung Cancer II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Thrombotic microangiopathy may be the first manifestation of solid tumors such as lung cancer. Thrombotic thrombocytopenic purpura (TTP) includes the pentad of thrombocytopenia, hemolytic anemia, fever, neurologic abnormalities, and renal disease. We present a case of acute TTP as the first presentation of lung cancer. Prompt recognition and management resulted in a good outcome. CASE PRESENTATION: A 56-year-old African American male with no significant PMH was transferred to our center with an altered mental status. The patient reports that he did not have recollection of the events surrounding his admission and he was having difficulty answering questions appropriately. Physical examination was normal. CBC showed normal leukocytes count, anemia, and platelets count of 16,000. Peripheral smear showed reticulocytosis and schistocytes. Chemistry revealed a mildly elevated creatinine, indirect bilirubin and AST. LDH was elevated. Routine chest X-ray revealed a 3 cm left upper lobe lung mass, a finding confirmed with a chest CT. Mass biopsy showed a poorly differentiated adenocarcinoma of the lung. He was started on plasmapheresis which resulted in short-lived improvement. He underwent a left upper lobe lobectomy, after which, he went into complete remission. DISCUSSION: Cancer related thrombocytopenia can result either from bone marrow metastasis or as a paraneoplastic process. TTP, commonly affects adults, is a life-threatening disseminated thrombotic microangiopathy. Patients rarely present with the pentad of TTP, and recognition of atypical cases and prompt management (plasmapheresis/treatment of underlying condition) is a key factor in improved survival. The presence of a primary malignancy is an essential concern in the differential diagnosis of TTP, particularly in patients with refractoriness to first-line therapy with plasmaperesis; however, sometimes the malignancy is not clinically obvious (as in our case), leading to an initial diagnosis of idiopathic TTP and subsequent plasmapheresis treatment. The treatment of the underlying malignancy may be the best therapeutic decision in paraneoplastic TTP given its poor response to standard treatments (as in our case). CONCLUSIONS: TTP is a medical emergency that is almost always fatal if exchange plasmapheresis is not initiated early. This case report reminds clinicians that TTP may be an atypical presentation of lung cancer and occult malignancy should always be kept in consideration in patients with thrombocytopenia of uncertain etiology. Reference #1: M. Khasraw, H. Faraj, and A. Sheikha. Thrombocytopenia in solid tumors. European Journal of Clinical and Medical Oncology, vol. 2, no. 2, pp. 89-92, 2010 Reference #2: Sevinc A, Kalender ME, Pehlivan Y, Sari I, Camci C.Thrombotic Thrombocytopenic Purpura and Bone Marrow Necrosis as the Initial Presentation of Lung Cancer. Clin Appl Thromb Hemost. 2007 Oct;13(4):449-52 Reference #3: Gastineau DA, Cancer-related TTP and considerations of plasma exchange. Oncology, 2011 Sep;25(10):924, 926 DISCLOSURE: The following authors have nothing to disclose: Ahmed Dirweesh No Product/Research Disclosure Information