Presence Of Schistocytes Research Articles

Thrombotic Thrombocytopenic Purpura: A Case Series from a Tertiary Care Centre in Northern India

Abstract: Thrombotic thrombocytopenic purpura is a medical emergency with varied clinical manifestations. High index of suspicion with careful evaluation of thrombocytopenia and hemolytic anemia is of paramount importance. Laboratory parameters of microangiopathic hemolytic anemia i.e. schitocytosis and increased LDH and indirect hyperbilirubinemia support the diagnosis. Plasma exchange is the treatment of choice. Post stem cell transplant TTP carries a poorer prognosis.Introduction:Thrombotic thrombocytopenic purpura (TTP) is a disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia associated with fever, renal dysfunction and neurological manifestations. Without treatment, TTP is almost uniformly fatal with a mortality rate approaching 90%. With the timely institution of therapeutic plasma exchange mortality decreases to about less than 10% (1). Recent reports indicate that rituximab can induce remission in the majority of patients with classic TTP (2). We report here 13 cases of TTP who were treated at our hospital in last 4 years. Six of these patients developed features of TTP post allogenic stem cell transplantation.Materials and Methods: The study included retrospective analysis of patients who presented with the features of TTP. Patients with characteristic features of TTP included two or more features among the pentad commonly considered diagnostic of TTP. Evidence of microangiopathic hemolytic anemia and thrombocytopenia were the minimal requirement for the diagnosis with or without fever, renal dysfunction and neurological manifestations. Coagulation profile included prothrombin time and APTT. Liver and kidney function analysis was done in all patients. Response was assessed by clinical and laboratory parameters with monitoring platelet counts, LDH, and schistocytes in the peripheral blood film. Patients with LDH in normal range and platelet counts more than 100,000/µl were considered to have achieved remission.Results: Patients with classic TTP recovered with plasma exchange and/or rituximab. Post-transplant TTP patients had a poorer prognosis as five out of six post-transplant TTP patients died.Discussion: TTP can have a varied clinical presentation and can be associated with many other diseases. Our case series highlight the varied manifestations and associations of TTP and their management and outcome. TTP is a medical emergency and needs high index of suspicion for the diagnosis. In our series, TTP was diagnosed by the findings of thrombocytopenia and hemolytic anemia evidenced by presence of schistocytes in the peripheral blood film and increased LDH, in the absence of coagulopathy. TTP should be suspected in the presence of microangiopathic hemolytic anemia and thrombocytopenia (1,3), and treatment should be started immediately, as delay in treatment can increase the mortality (1). Plasma exchange has changed the prognosis of this highly fatal disease to a highly curable disease. Rituximab has further improved the management of TTP (2). Patients with classic TTP were treated with plasma exchange but 3 patients also required rituximab. All patients with classic TTP are in remission.Transplant-associated microangiopathy (TAM) is a MAHA and thrombocytopenia that occurs after bone marrow transplantation. Patients with post-transplant TTP were diagnosed based on thrombocytopenia and features of microangiopathic hemolytic anemia with schistocytosis and raised LDH, in the absence of coagulopathy. They were treated with FFP and steroids, as plasma exchange is not beneficial for post-transplant TTP (1). Repeated plasma exchange with increased frequency and/or rituximab therapy are the agents of choice in relapsing disease (3). Rituximab is a safe and effective treatment for newly diagnosed TTP, and has been shown to decrease the number of plasma exchange required to achieve remission. We used rituximab in 3 patients and all improved. Post transplant MAHA carried poor prognosis.Conclusion: Diagnosis of TTP requires a high index of suspicion and prompt treatment with plasma exchange, which results in a high cure rate. Rituximab is useful in patients relapsing or showing partial recovery. Plasma exchange has not been reported to be effective in post-transplant TTP.Acknowledgment: We are thankful to Ms Bharti Sharma for compiling the data. DisclosuresNo relevant conflicts of interest to declare.

The occurrence of thrombotic thrombocytopenic purpura during treatment of HCV with direct-acting antiviral agents

Background and aim Experts have reported thrombocytopenia linked to chronic liver disease in up to 70% in patients with advanced fibrosis and portal hypertension. Thrombotic thrombocytopenic purpura (TTP) occurrence with HCV infection is a rare and life-threatening event. We aimed to investigate the cause of disturbed conscious level, acute hemolytic anemia, and severe thrombocytopenia in a male patient with chronic HCV and under treatment with direct-acting antivirals. Case report: Development of severe thrombocytopenia, acute hemolytic anemia, neurological symptoms in the form of fits and coma in a 32- year- old man with chronic HCV infection after one week of treatment with direct-acting antivirals (sofosbuvir 400mg PO daily, and daclatasvir 60 mg PO daily). Brain CT was normal, with a negative Coombs test and the presence of schistocytes in the peripheral blood smear. The patient presentation was suggestive of thrombotic thrombocytopenic purpura (TTP). Conclusion: This is a case of TTP after one week of direct-acting antiviral drugs despite the safety profile of these medications. Studying the pathophysiology of TTP after DAAs needs more clarifications.

Acute revascularization syndrome following successful treatment of chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a rare condition, usually caused by stenosis or occlusion of two visceral arteries. As its early symptoms are unspecific, this condition can be diagnosed late or misdiagnosed. Duplex ultrasound or CT angiography or MR angiography is available to reach the diagnosis. Open surgical or endovascular revascularization are two valid options in CMI, even if there is not an evidence-based technique recommended for its intervention. Morbidity and 30-day mortality differ based on the option chosen. We discuss a case of 59-year-old woman referred for chronic post prandial abdominal pain and weight loss. A computed tomography angiogram (CTA) of the chest, abdomen and pelvis with multiplanar and centerline reconstructions of the mesenteric vessels revealed a multivessel splanchnic mesenteric occlusive disease. We treated her with hybrid revascularization: a retrograde iliac-SMA bypass was performed using a 6-mm diameter PTFE graft end-to-side with SMA and a 5x12mm balloon-expandable stent was inserted into the main trunk of the IMA, via retrograde IMA access. After the second post-operative day, the patient developed several complications: chest pain associated with dyspnea, abdominal pain with diarrhea and melena, oliguria, sinus tachycardia and laboratory tests’s alterations (anemia, neutrophilic leucocytosis, thrombocytopenia, hyperbilirubinemia, increase in transaminases, troponin I and serum creatinine). A CT scan showed a normal perfusion of the aortic-SMA by-pass and a normal perfusion of the IMA stenting. Blood smear examination revealed presence of schistocytes. The etiopathogenesis was probably a thrombotic microangiopathy due to revascularization of both SMA and IMA. The patient was successfully treated with high volume fresh plasma infusion and red blood cells units. For those patients an early diagnosis should be considered, together with an aggressive treatment in the case of occurrence of a systemic inflammatory response syndrome. We therefore suggest to treat these patients only in centers which have the availability of multidisciplinary monitoring and adequate treatment options. No cases of revascularization syndrome after treatment for CMI are reported in literature.

Bone marrow transplant-associated thrombotic microangiopathy without peripheral blood schistocytes: a case report and review of the literature

BackgroundBone marrow transplant-associated thrombotic microangiopathy (TA-TMA) is a relatively frequent but under-recognized and under-treated hematopoietic stem cell transplant (HSCT) complication that leads to significant post-transplant morbidity and mortality. Classic TMA-defining laboratory abnormalities appear at different times in the course of TA-TMA development, with schistocytes often appearing later in the disease course. In some severe TMA cases, schistocytes may be absent due to increased endothelial permeability. Unfortunately, many clinicians continue to perceive the presence of schistocytes as an absolute requirement for TA-TMA diagnosis, which leads to delayed recognition and treatment of this potentially fatal transplant complication.MethodsPatient chart review and PubMed literature search using the term, “transplant-associated thrombotic microangiopathy”.Case presentationA 54-year-old male IgG kappa multiple myeloma underwent a reduced intensity allogeneic HSCT from a 9/10 HLA-matched unrelated donor after conditioning with fludarabine and melphalan. On day + 27, the patient developed acute kidney injury followed by repeated episodes of diarrhea and gastrointestinal bleeding attributed to graft versus host disease (GVHD) and cytomegalovirus (CMV) colitis. Repeated colonic biopsies suggested CMV infection and GVHD. Despite appropriate treatment with antiviral therapy and immunosuppressants, the patient’s condition continued to deteriorate. He experienced concomitant anemia and thrombocytopenia as well as elevated lactate dehydrogenase and low haptoglobin levels, but a TA-TMA diagnosis was not made due to an absence of schistocytes on peripheral smear. The patient expired secondary to uncontrolled gastrointestinal bleeding. A post-mortem analysis of the resection specimen revealed extensive TMA involving numerous arteries and arterioles in the ileal and colonic submucosa as well as in the muscularis propria and deep lamina propria of the mucosa.ConclusionsTA-TMA can occur in the absence of peripheral blood schistocytes. Our experience underscores the importance of considering the diagnosis of intestinal TA-TMA in patients with refractory post-transplant diarrhea and GI bleeding, even if all classic features are not present.

Comparison of Renal Outcome among Japanese Patients with or without Microangiopathic Hemolysis in Malignant Phase Hypertension: A Single-Center Retrospective Study

Background/Aims: Although microangiopathic hemolysis (MAH) is a well-known complication of malignant phase hypertension (MPH), only less data on whether MAH in MPH predicts renal outcome exist. Therefore, we evaluated whether MAH was associated with the renal outcome in patients with MPH. Methods: We conducted a single-center, retrospective, cohort study. Data from 35 patients diagnosed with MPH between October 1998 and January 2015 were analyzed. MPH was defined as the presence of a diastolic blood pressure of ≥120 mm Hg and grades III/IV hypertensive retinopathy according to the Keith-Wagener-Barker classification. MAH was defined as the presence of a low platelet count (<150 × 10⁹/L) together with either an elevated level of lactate dehydrogenase (LDH; >220 U/L), or the presence of schistocytes, or both and the normalization of platelet and LDH level or schistocyte levels after adequate blood pressure control was achieved. The primary outcome was dialysis induction. Results: Fifteen patients had MAH. Those with MAH had significantly severe renal dysfunction at the onset of MPH. The length of follow-up (median, interquartile range) of patients with MAH and those without MAH were 30 (16-94) and 48 (25-115) months, respectively. Dialysis was induced in 9 of 15 patients with MAH and in 6 of 20 patients without MAH. Renal survival in patients with MAH was worse than that in those without, but this was not statistically significant (p = 0.08). By multivariate Cox regression analysis, MAH was not shown to contribute to dialysis induction. Conclusion: MAH did not predict renal outcome in MPH.

Clinical dissection of thrombotic microangiopathy.

Differential treatment strategies are applied in thrombotic microangiopathy (TMA) according to the sub-classifications. Hence, it is worthwhile to overview clinical manifestations and outcomes of overall TMA patients according to sub-classifications. We analyzed TMA patients whose serum lactate dehydrogenase levels >250IU/L, with the presence of schistocytes in their peripheral blood smear, or with typical vascular pathologic abnormalities in their renal biopsy. We compared clinical manifestations including overall survival (OS) and renal survival according to TMA causes. A total of 117 TMA patients (57 primary and 60 secondary TMA) were analyzed. Renal symptom was the most common manifestation in whole patients, while renal function at diagnosis was worst in pregnancy-related TMA group. Primary TMA patients had more frequent CNS symptom and hematologic manifestation compared to secondary TMAs. Among secondary TMAs, pregnancy- and HSCT-related TMA patients showed prevalent hemolytic features. During 150.2months of follow-up, 5-year OS rate was 64.8%. Poor prognostic factors included older age, combined hematologic and solid organ malignancies, lower hemoglobin levels, and lower serum albumin levels. There was no significant difference in OS between primary and secondary TMAs. Seventy-eight percent of patients experienced AKI during TMA. Five-year death-censored renal survival rate was poor with only 69.2%. However, excellent renal outcome was observed in pregnancy-associated TMA. TMA showed various clinical manifestations according to their etiology. Notably, both OS and renal survival were poor regardless of their etiologies except pregnancy-associated TMA. Physicians should differentiate a variety of TMA categories and properly manage this complex disease entity.

A study of disseminated intravascular coagulation in acute leukemia reveals markedly elevated D-dimer levels are a sensitive indicator of acute promyelocytic leukemia.

While the presence of disseminated intravascular coagulation (DIC) has been implicated in worse clinical outcome in acute leukemia, the relationship between different subtypes of acute leukemia and the clinicopathologic features of DIC has not been systematically well studied. In this study, we retrospectively reviewed 149 cases of newly diagnosed acute leukemia and assessed the utility of evaluating red blood cell morphologic features, and coagulation parameters in determining the presence of DIC as well as differentiating subtypes of acute leukemia. Review of our cohort demonstrates a novel finding, that elevated D-dimer concentrations ≥19 000 ng/mL fibrinogen equivalent units (FEU) are a sensitive diagnostic indicator of acute promyelocytic leukemia (APL) with moderate specificity, sensitivity 96%, specificity 92% in acute leukemia subtyping. Similar to other studies, APL showed an increased incidence of DIC (P < 0.01) compared to other subtypes of acute leukemia. Surprisingly, the presence of schistocytes on the peripheral blood smear was not a statistically significant indicator of DIC, sensitivity of 36% and specificity of 89%. Finally, the presence of DIC was not a significant indicator of poorer prognosis amongst all patients with AML. Overall we identify elevated D-dimer concentrations ≥19 000 ng/mL FEU are a sensitive indicator of acute promyelocytic leukemia (APL), with a sensitivity of 96% and specificity of 92% in the subtyping of acute leukemias, and that the presence of schistocytes in peripheral blood smears is not a diagnostically sensitive screening test for DIC with a sensitivity of 36%.

Morphological Changes of Red Blood Cells in Peripheral Blood Smear of Patients with Pregnancy-related Hypertensive Disorders

Pregnancy-related hypertensive disorders are complications in which risk factors are identified such as nulliparity, age, malnutrition, obesity and social issues. Those statements are explained by theories of abnormal placentation, immunological inadequacy, genetics and oxidative stress, but all theories converge in endothelial damage, which is able to mechanically deform and hemolyze erythrocytes as they pass through the capillaries. Given the effects of endothelial damage, the aim of the study was to determine erythrocyte alterations in peripheral blood smear of patients with hypertensive disorders of pregnancy that could be used as prognostic condition. We performed a prospective, descriptive and observational study where all patients with hypertensive disorders admitted to the obstetrics and gynecology service of a specialty hospital were recruited. Patients who provided signed informed consent underwent peripheral blood smear. Results were tabulated in percentage graphics and analyzed with Cramer's V based on χ(2). The peripheral blood smear consisted of an extended drop of peripheral blood from the patient with subsequent hematological staining done with Romanowsky stain. A total of 119 samples were analyzed; 74% showed abnormal morphology of erythrocytes and the most frequent abnormality was the presence of schistocytes in up to 39% of samples. Descriptive analysis showed a degree of association to independent variables with Cramer's V=0.41 value (p<0.05). A high percentage of patients with hypertensive disorders of pregnancy show some morphologic alterations of erythrocytes in peripheral blood smear.

International society on thrombosis and haemostasis disseminated intravascular coagulation scoring system: Is it a good prognostic indicator in DIC

Background: Disseminated intravascular coagulation is an acquired disorder characterized by intravascular activation of coagulation due to variety of causes. There is excessive thrombin formation leading to fibrin deposition in microcirculation and consequent ischemic organ damage. The diagnosis is essentially clinical supported by laboratory parameters and a scoring system based on these. The mainstay of treatment is correction of underlying cause and haemostatic support with replacement of coagulation factors. Aim: To evaluate the use of ISTH DIC scoring system in patients of clinically suspected Disseminated Intravascular Coagulation. Methods: 60 cases were studied over a period of one year. Patients were selected with a clinical suspicion of DIC who are having an underlying predisposing condition. Clinical signs and symptoms were recorded. Routine investigations and the tests necessary to calculate the ISTH score i.e. platelet count, Prothrombin time; D-dimer and Fibrinogen were done. The scoring criteria of ISTH were applied in these cases. Chi square and Fisher’s exact tests were used for analysis of the data. Results: The commonest cause of the underlying disorder in our study was found to be Sepsis (66.7%) followed by trauma (10%), obstetric causes (8.3%) and solid malignancy (6.7%). There was a significant association of ISTH score with outcome of the patients (P value <0.05). Raised APTT and presence of schistocytes also had a significant association with a high ISTH score. Conclusion: ISTH DIC scoring criteria more precisely define clinical and laboratory parameters of DIC. Its clinical utility will improve the timely diagnosis, prediction of severity and will also aid in improving prognosis of DIC patients.

Automated Detection and Classification of Schistocytes by a Novel Red Blood Cell Module Using Digital Imaging/Microscopy

To the Editor The detection of morphological red blood cell (RBC) abnormalities is of vital importance in a variety of diseases. For thrombotic thrombocytopenic purpura (TTP), the presence of schistocytes in a peripheral blood smear is a major criterion for the diagnosis. TTP is an acute life-threatening disease in which the protein ADAM-TS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif, member 13) is ineffective (e.g. due to the presence of antibodies to ADAM-TS13). The function of this protein is cleavage of the coagulation protein von Willebrand factor (VWF) into smaller pieces [1]. Since ADAM-TS13 is inactive, blood clots are formed more rapidly which capture thrombocytes, resulting in a thrombocytopenia. Erythrocytes are fragmented by these clots, leading to hemolytic anemia and schistocytes. Patients often present with fever, hemorrhage, neurological symptoms, petechia and renal damage. Alongside, an increased lactate dehydrogenase (LDH) and a decreased haptoglobin are seen. Schistocytes are morphologically polymorphic, which complicates the detection and identification. Also, a consistent and standardized international grading system for aberrant RBCs is still lacking nowadays [2]. The grading of abnormal RBCs is shown by a number of plus signs, which stands for the percentage of abnormal cells. In our laboratory, schistocytes are indicated with 1+, 2+ and 3+ (which stand for 0.5-2%, 2-5% and > 5% schistocytes) [3], but these percentages vary per laboratory. Recently a novel application module (Advanced RBC application, Cellavision) for the digital microscope was developed to automatically detect and classify morphological abnormalities of RBCs. This application actually works as a RBC-locating device. RBCs are identified and segmented by the system, after which each RBC is characterized for shape, size, color and inclusion. An artificial neural network is responsible for these characterizations, which is trained by a number of highly qualified experts. This neural network uses 80 features calculated for each RBC image. Some examples of used features are roundness, size, distribution of notches around the border and size and shape of inner pallor. The suggested morphology by the system can be changed or verified by the user. The results are represented as a percentage value and a grading which is based on a conversion table defined by the user in the settings file. With the use of digital imaging and this novel RBC mod

DI-001 Ciclosporin-associated thrombotic microangiopathy

BackgroundThe development of thrombotic microangiopathy (TPP) is well documented in organ transplant recipients, in most cases associated with calcineurin inhibitors. The mechanism by which TPP arises is from inhibition of...

Hemolytic uremic syndrome associated with Plasmodium vivax malaria successfully treated with plasma exchange

We report a case of hemolytic uremic syndrome (HUS) in an adult patient with Plasmodium vivax malaria. The patient presented with worsening anemia, persistent thrombocytopenia and acute kidney injury. HUS was diagnosed based on the high serum lactate dehydrogenase, elevated reticulocyte count and presence of schistocytes on peripheral blood smear. Kidney biopsy showed features of thrombotic microangiopathy. Complete hematological remission was achieved after five sessions of therapeutic plasma exchange. Renal function partially recovered and stabilized at discharge. Vivax malaria, generally considered benign, may be rarely associated with HUS.

Schistocytes in disseminated intravascular coagulation

The presence of schistocytes on the peripheral blood film during disseminated intravascular coagulation (DIC) remains controversial. We examined schistocytes count on blood films from 35 DIC patients and checked morphological anomalies of all RBCs. Thirty of 35 patients presented with schistocytes and 22 with acanthocytes, which was the commonest shape anomaly. Mean percentage ± standard deviation was 0.33 ± 0.38%, median value was 0.1%, and range was 0-1.4%. The patients with schistocytes ≥ 1% had circumstances frequently associated with increased schistocytes count (promyelocytic leukaemia, pregnancy, severe infection). Schistocytes were thus frequently observed in DIC patients, usually with low percentage, within or close to the reference range (<0.5%). Schistocytes measurement is not a clue test for the initial diagnosis of DIC, but might be of clinical value to suggest an associated or underlying thrombotic microangiopathy if ≥ 1%.

Acute leukemoid reaction associated with liver surgery for metastatic colorectal cancer

Dear Editor: A 48-year-old woman was referred to our department for management of colorectal cancer metastatic to the liver. Past medical and hematological history was nonsignificant. Past surgical history included sigmoidectomy for colonic adenocarcinoma with synchronous bilobar liver disease 1 year ago in a peripheral hospital. Following surgery, she had received first line chemotherapy ensued by treatment with bevazicumab due to a favorable K-ras status. At presentation to our hospital, liver disease showed a 60 % response to chemotherapy. We planned a two-staged hepatectomy, a right portal vein ligation combined with left liver lobe metastasectomies followed by a right hepatectomy 5 weeks later. The first operation ran uneventfully, and we proceeded to the next stage after a preoperative CT confirming an adequate left hemiliver volume. The patient underwent an anatomical right hemihepatectomy. During the immediate postoperative period, she gradually developed an obstructive jaundice (peak value: total bilirubin 12 mg/dl, direct bilirubin 9 mg/dl). Her white blood cell counts ranged between 7× 10/L and 16×10/L during the same time period. Due to persistent hyperbilirubinemia, an abdominal ultrasound exhibiting notable intrahepatic biliary tree dilatation and a MRCP not illustrating the extrahepatic biliary structures, we decided to proceed to surgery. At relaparotomy, we observed a 180° malrotation around the common bile duct due to malposition of the liver remnant into the abdominal cavity. A Rouxen-Y hepatojejunostomy was tailored across segments II and III, and the hemiliver was repositioned. The patient was directly extubated and transferred to the surgical ward. Surprisingly, her first blood counts postoperatively showed marked leukocytosis [white blood counts (WBC):53×10/L], with a neutrophilic differential (neutrophils 93 %). Her WBC continued to increase during the following hours, peaking at 93×10/L on the second postoperative day. Of note, the patient was afebrile without any septic-related symptoms or signs during this time period. A hematology consultation was pursued. Her clinical examination was non-remarkable. No hepatosplenomegaly or lymphadenopathy was present. The white blood cell differential was as follows: 95 % neutrophils, 2 % bands, 2 % lymphocytes and 1 % monocytes. The blood smear showed mature normally lobated neutrophils without toxic granulation. Occasional bands were noted without a left shift. Red blood cells were of normal morphology without the presence of schistocytes. Platelets were within normal limits regarding number and morphology. At this juncture, a detailed work-up was undertaken to rule out infection and sepsis. C-reactive protein, blood cultures, disseminated intravascular coagulation panel, urinalysis, and culture, as well as chest X-ray were within normal limits. Her WBC gradually declined to normal level during the following 5 days, and the patient was discharged 2 weeks later. Persistent neutrophilic leukocytosis exceeding 50×10/L and peaking as high as 180×10/L in noninfected patients with malignant, non-hematopoietic neoplasias is termed a leukemoid reaction. The exact pathophysiology underlying this excessive leukocytosis is yet unclear. Various reports on solid tumors associated with neutrophilic leukocytosis suggest that paraneoplastic cytokine production by the primary tumor induces granulocytic overproduction, therefore resulting in a leukemoid reaction. Indeed, production of granulocyte colony-stimulating factor, granulocyte–macrophage–CSF, interleukin-1, and/or interleukin-6 by several aerodigestive G. C. Sotiropoulos (*) : P. Charalampoudis :G. Kouraklis 2nd Department of Propedeutic Surgery, University of Athens Medical School, Laikon Hospital, 17 Agiou Thoma Street, Athens 11527, Greece e-mail: georgios.sotiropoulos@uni-due.de

Evaluation of schistocytes measurement guidelines

The schistocytes are fragmented red blood cells mainly observed in the setting of hemolytic anemias and particularly among the thrombotic microangiopathies. The presence of schistocytes is an important criterion for the diagnosis of mechanical anemias, though the identification of these cells remains problematic. As a high variability of the morphologic identification criteria of the schistocytes among morphologists has been observed, some guidelines have been proposed after workshops (French and Italian groups). The International council for standardization in hematology published a consensus in November, 2011. The French group of cellular hematology (GFHC) aimed to recover the opinion of French biologists directly confronted to schistocytes measurements. 169 out 500 (34%) answered 10 questions dealing with the identification and measurements of schistocytes as proposed by the ICSH guidelines. A consensus was reached for the urgent need of guidelines documents, moreover in the current background of the European accreditation NF EN ISO 15189 rules. A traduction in native (French) language as warmly wished in order to facilitate the diffusion of the information. New fragmented red cell parameter recently provided by 2 manufacturers of automated blood cell counters remained doubtfull for routine use for half of the biologists.

Rapid Identification of Thrombocytopenia-Associated Multiple Organ Failure Using Red Blood Cell Parameters and a Volume/Hemoglobin Concentration Cytogram

Thrombocytopenia-associated multiple organ failure (TAMOF) has a high mortality rate when not treated, and early detection of TAMOF is very important diagnostically and therapeutically. We describe herein our experience of early detection of TAMOF, using an automated hematology analyzer. From 498,390 inpatients, we selected 12 patients suspected of having peripheral schistocytosis, based on the results of red blood cell (RBC) parameters and a volume/hemoglobin concentration (V/HC) cytogram. We promptly evaluated whether the individual patients had clinical manifestations and laboratory findings were consistent with TAMOF. Plasma exchanges were then performed for each patient. All 12 patients had TAMOF. The mean values of RBC parameters were significantly higher in all of the patients than with the reference range, however, 3 patients had % RBC fragments within the reference range. The mean value of ADAMTS-13 activity was slightly lower in patients compared with the reference range. Of the 12 patients, remission was obtained in 9 patients (75%) within 4 to 5 weeks using plasma exchanges. Three patients died. An increased percentage of microcytic hyperchromic cells with anisocytosis and anisochromia indicated the presence of schistocytes, making it an excellent screening marker for TAMOF. Identification of TAMOF with RBC parameters and a V/HC cytogram is a facile and rapid method along with an automated hematology analyzer already in use for routine complete blood cell counting test.

Acute Pancreatitis Induced by Activated Polyamine Catabolism Is Associated with Coagulopathy: Effects of α-Methylated Polyamine Analogs on Hemostasis

Background/Aims: Polyamines are ubiquitous organic cations essential for cellular proliferation and tissue integrity. We have previously shown that pancreatic polyamine depletion in rats overexpressing the catabolic enzyme, spermidine/spermine N1-acetyltransferase (SSAT), results in the development of severe acute pancreatitis, and that therapeutic administration of metabolically stable α-methylated polyamine analogs protects the animals from pancreatitis-associated mortality. Our aim was to elucidate the therapeutic mechanism(s) of α-methylspermidine (MeSpd). Methods: The effect of MeSpd on hemostasis and the extent of organ failure were studied in SSAT transgenic rats with either induced pancreatitis or lipopolysaccharide (LPS)-induced coagulopathy. The effect of polyamines on fibrinolysis and coagulation was also studied in vitro. Results: Pancreatitis caused a rapid development of intravascular coagulopathy, as assessed by prolonged coagulation times, decreased plasma fibrinogen level and antithrombin activity, enhanced fibrinolysis, reduced platelet count and presence of schistocytes. Therapeutic administration of MeSpd restored these parameters to almost control levels within 24 h. In vitro, polyamines dose-dependently inhibited fibrinolysis and intrinsic coagulation pathway. In LPS-induced coagulopathy, SSAT transgenic rats were more sensitive to the drug than their syngeneic littermates, and MeSpd-ameliorated LPS-induced coagulation disorders. Conclusion: Pancreatitis-associated mortality in SSAT rats is due to coagulopathy that is alleviated by treatment with MeSpd.

Postoperative Thrombotic Thrombocytopenic Purpura After Open Heart Operations

Postoperative thrombotic thrombocytopenic purpura (pTTP) after cardiovascular operations has an alarmingly high mortality rate if untreated. Five patients after coronary artery bypass graft (CABG) procedure were diagnosed with pTTP when they were observed to have a persistent thrombocytopenia associated with symptoms of fever, renal insufficiency, thromboembolic events, or altered mental status in conjunction with a microangiopathic hemolytic anemia (MAHA). A guideline for early diagnosis, followed by timely treatment in these cases, is reviewed. A retrospective record review of postoperative patients with thrombocytopenia identified 5 patients that met the criteria for pTTP from 2004 to 2008. We examined these 5 cardiovascular surgical patients in terms of clinical presentation, laboratory data, and outcomes. All patients had the combination of an unexplained thrombocytopenia (platelets < 50,000 mm(3)) in conjunction with a MAHA as determined by the presence of schistocytes. Symptoms of neurologic dysfunction and renal insufficiency developed in all patients. Thromboembolic events were noted in 1 patient. All patients underwent plasmapheresis. In 3 patients, response time to clinical recovery and normalization of hematologic laboratory values after plasmapheresis was 3, 4, and 8 days. Two patients did not recover and died. One patient had a clinical and laboratory recovery after 19 days of plasmapheresis; however, after 11 days, thrombocytopenia with MAHA developed and he died on day 53 from complications related to the operation. Postoperative TTP should be recognized as a possible pathophysiologic mechanism for unexplained postoperative thrombocytopenia and treatment should be initiated once the diagnosis is established.

Cancer-related TTP: Role of plasma exchange

e13527 Background: Thrombotic thrombocytopenic purpura (TTP) is a multisystemic disease classically described by thrombocytopenia, microangiopathic hemolytic anemia, fever, neurologic manifestations and renal dysfunction. It is considered a hematologic emergency for which, the treatment of choice is plasma exchange therapy. However, its diagnosis and treatment can be particularly challenging in the setting of disseminated malignancy, as the misdiagnosis of TTP in a patient with cancer-associated thrombotic microangiopathy (TMA) will lead to ineffective use of plasma exchange and delay the timely delivery of chemotherapy. Moreover, patients with disseminated malignancy respond less often to plasma exchange and have a higher mortality rate. Methods: Three patients with disseminated malignancy who presented as TTP are discussed. Two of the three patients were given plasma exchange and had fatal outcomes, while the third patient received chemotherapy as the initial therapy and survived hospitalization. The three patients had prolonged PT with normal aPTT; LDH levels (&gt;1,000 IU/L); and presence of schistocytes in the peripheral blood smear. Results: TMA associated with disseminated malignancy remains a challenging and underdiagnosed condition with very poor prognosis. Plasma exchange has no clinical use is potentially even life-threatening especially when it delays the administration of the appropriate chemotherapy which is the ultimate treatment for the underlying malignancy that resulted in TMA. We propose that the following criteria be used for diagnostic consideration of disseminated malignancy-associated TMA: evidence of hemolysis; leukoerythroblastic picture on the peripheral blood; coagulopathy consisting of elevated d-dimer, prolonged PT with normal aPTT; extreme elevations in the LDH levels (&gt;1,000 IU/L); and presence of schistocytes in the peripheral blood smear. Such patients should be immediately considered for a bone marrow biopsy as chemotherapy should be initiated as soon as possible. Conclusions: See Table. [Table: see text] No significant financial relationships to disclose.

Thrombotic Microangiopathy with Tacrolimus/Sirolimus-Based GVHD Prophylaxis Regimen in Patients Undergoing Hematopoietic Stem Cell Transplant from a Matched Unrelated Donor

Thrombotic microangiopathy (TMA) is a multifactorial complication of related and unrelated allogeneic hematopoietic stem cell transplant (allo-HSCT). The true incidence of TMA is difficult to estimate due to lack of agreement on a single definition. Diagnosis is often complicated by multiple potential etiologies for the clinical findings. Sirolimus (SIR), an inhibitor of mammalian target of Rapamycin (mTOR), is a novel immunosuppressive agent that works synergistically with calcineurin inhibitors (CNI) to prevent graft-versus-host disease (GVHD) in allo-HSCT. Recently, the addition of SIR to CNIs was reported to result in a higher than expected incidence (10.8%) of TMA (Cutler et al. BBMT 2005; 11:551–7). We evaluated the incidence and risk factors for TMA in a cohort of patients undergoing matched unrelated (MUD) HSCT using SIR combined with tacrolimus (TAC) and mini-methotrexate for GVHD prophylaxis at City of Hope. TMA was defined as SCr increase of ≥ 50% above baseline, LDH twice the institutional upper normal limit, presence of schistocytes or persistent presence of nucleated red blood cells, and prolonged or progressive thrombocytopenia (platelets <50 × 109/L or ≥ 50% decrease from previous count). A case series of 47 MUD-HSCT patients were included in this retrospective chart review study. The median age was 50 years (range: 19–67); (male/female: 28/19). Conditioning regimens consisted of fludarabine/melphalan (65%) and FTBI combined with cyclophosphamide or etoposide (35%). Diagnoses included ALL (32%), AML (25%), NHL (15%), MDS (15%), MPD (9%), CML (2%), CLL (2%). Twenty-six patients (55%) had a 10/10 matched (HLA-A, B, C, DRB1, and DQB1) donor by high-resolution on typing. The median follow up for the 30 surviving patients is 14.5 months (2.8–26). The one-year probabilities of overall survival and non-relapse mortality (NRM) were 61% and 19%, respectively. Grade II-IV acute GVHD (aGVHD) was reported in 60% of all patients (grade III-IV: 25%). Thirteen (28%) patients met the above diagnostic criteria for TMA. In addition, we included two patients who did not meet the criteria due to missing tests but were clinically diagnosed with TMA by independent attending physicians, resulting in the total incidence of 32% (15/47). Four of the 15 patients met the criteria for TMA as a result of ongoing multi-organ failure secondary to other causes. The median time to TMA onset was five weeks (2–20 weeks). Most cases (93%) occurred within the first 100 days post-HSCT. Thirteen patients developed both TMA and aGVHD, in which the majority of patients (70%) developed TMA after a diagnosis of aGVHD had been made. Initial treatments for TMA included holding TAC (33%), holding SIR (20%), holding or adjusting doses (27% and 20%, respectively) for both drugs. One patient underwent plasma exchange. Sixty percent of patients subsequently recovered from TMA as defined by normalization of laboratory values. Of the 17 expired patients, ten were diagnosed with TMA. Causes of death were as follows: for TMA cases, relapse mortality=3, NRM=7; for Non-TMA patients, relapse mortality=6, NRM=1. At the time of TMA diagnosis, the median TAC and SIR levels were 11.3 (0–18.8) and 7 (0–23.9) ng/ml, respectively, in contrast to the median TAC and SIR levels for non-TMA patients at 6.1 (p= 0.02) and 5.5 (p=0.13) ng/ml, respectively. To identify other possible risk factors for TMA, the following patient and treatment-related characteristics were examined: age, conditioning regimen, disease type, degree of HLA match, and exposure to triazole antifungals. Only higher tacrolimus levels (HR: 6.9, p<0.01) and aGVHD grades III-IV (HR: 3.5, p=0.02) were associated with an increased risk for TMA. In conclusion, TMA is common after MUD allo-HSCT using SIR-containing GVHD prophylaxis. The risk factors for TMA suggest that careful monitoring and adjustment of TAC/SIR dosages to avoid super-therapeutic levels is critical, particularly during ongoing GVHD.