Multidisciplinary Treatment in Toxic Epidermal Necrolysis

Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.

Rapid resolution of hypertriglyceridemia-induced pancreatitis via plasmapheresis: A unique case report

Hypertriglyceridemia is a well-established cause of acute pancreatitis. Initial treatment for hypertriglyceridemia-induced pancreatitis has consisted of supportive measures; however, triglyceride levels can remain high, causing prolonged organ failure and sepsis. Plasmapheresis has been proposed as a treatment option to effectively reduce triglyceride levels. We present a patient case of hypertriglyceridemia-induced pancreatitis that was treated with standard acute pancreatitis interventions along with plasmapheresis, after which triglyceride levels reduced significantly. Further research is necessary to determine the clinical benefits of plasmapheresis in treating this type of pancreatitis.

Immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy: a potential therapeutic option

OBJECTIVE

Removal of cardiac autoantibodies by immunoadsorption might confer clinical improvement in dilated cardiomyopathy. In this pilot study, we investigated the efficacy and safety of immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy.

METHODS

This study consisted of 9 heart failure patients with dilated cardiomyopathy, NYHA III-IV, left ventricular ejection fraction <30%, unresponsive to heart failure therapy, and with cardiac autoantibodies. Patients underwent immunoadsorption therapy for five consecutive days using a tryptophan column. Changes in cardiac function (left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-systolic diameter), exercise capacity (6-minute walk distance), neurohormonal (N-terminal pro-brain natriuretic peptide), proinflammatory (high-sensitive C-reactive protein), and myocardial (cardiac troponin-I), biochemical, and hematological variables were obtained at baseline and after 3 and 6 months of immunoadsorption therapy.

RESULTS

Mean left ventricular ejection fraction and 6-minute walk distance significantly increased at 3 months (from 23.27±5.09 to 32.1±1.7%, p=0.01 for left ventricular ejection fraction and from 353±118 to 434±159 m, p=0.04 for 6-minute walk distance) and further increased at 6 months after immunoadsorption therapy (to 34.5±7.7%, p=0.02 for ejection fraction and to 441±136 m, p=0.04 for 6-minute walk distance). NT-proBNP level reduced from 1161(392.8-3034) to 385(116.1-656.5) ng/L (p=0.04), and high-sensitive C-reactive protein decreased from 9.74±0.96 to 4.3±5.8 mg/L (p=0.04) at 6 months. Left ventricular end-diastolic diameter (66.1±5.8 vs. 64.7±8.9 mm) and left ventricular end-systolic diameter (56.1±8.6 vs. 52.3±10.8 mm) tended to decrease but did not reach statistical significance. No significant worsening was observed in creatinine, cardiac troponin-I, and hemoglobin levels after the immunoadsorption procedure.

CONCLUSION

In dilated cardiomyopathy patients with refractory heart failure, immunoadsorption may be considered a potentially useful therapeutic option to improve a patient's clinical status.

Thrombotic Microangiopathy in the Setting of Colorectal Cancer: A Therapeutic Challenge with a Bad Prognosis

While most cases of thrombotic microangiopathic hemolytic anemias are idiopathic, some can occur in the setting of a malignancy. Differentiating both conditions is crucial to initiate the appropriate treatment. In this case report and literature review, we discuss the occurrence of a thrombotic microangiopathy in a 61-year-old male patient with a treatment-refractory metastatic colorectal cancer invading his bone marrow. Plasmapheresis does not constitute the mainstay of treatment in this setting, as targeting the primary disease is the ultimate management. Treating the condition of our patient has been challenging as multiple lines of treatments of his primary disease had been exhausted. The discrepancy in KRAs status obtained between PCR and later NGS offered a new treatment line with Cetuximab. In this article, we will discuss the different factors that differentiate between idiopathic and cancer-induced microangiopathy. We will emphasize on the fact that the treatment of the primary disease constitutes the most important step in the treatment of cancer-induced thrombotic microangiopathy. We will also raise several explanations to target the disagreement in KRAS status obtained by the different technical modalities.

Comparative Analysis of Determinants and Outcome of Early and Late Acute Antibody Mediated Rejection (ABMR)

Introduction

Antibody-mediated rejection (ABMR) is one of the major determinants of graft survival. Although diagnostic precision and treatment options have improved, response to therapy and graft survival has not improved very significantly. The phenotypes of early and late acute ABMR differ in many ways. In this study, we assessed the clinical characteristics, response to therapy, DSA positivity, and outcomes of early and late ABMR.

Methods

During the study period, 69 patients with acute ABMR diagnosed on renal graft histopathology were included with a median follow-up of 10 months after rejection. Recipients were stratified into early acute ABMR (<3 months of transplant; n = 29) and late acute ABMR (>3 months of transplant; n = 40). Graft survival, patient survival, response to therapy, and doubling of serum creatinine were assessed and compared between the two groups.

Results

Baseline characteristics and immunosuppression protocols were comparable between the early and late ABMR groups. Late acute ABMR had an increased risk of doubling of serum creatinine than the early ABMR group (P = 0.002). Graft and patient survival were not statistically different between the two groups. Response to therapy was inferior in the late acute ABMR group (P = 0.00). Pretransplant DSA was present in 27.6% in the early ABMR group. Late acute ABMR was frequently associated with nonadherence or suboptimal immunosuppression and low DSA positivity (15%). Infections such as CMV, bacterial, and fungal infections were similar in the earlier and late ABMR groups.

Conclusion

Late acute ABMR group had a poor response to anti-rejection therapy and also an increased risk of doubling of serum creatinine compared to the early acute ABMR group. There was also a tendency toward increased graft loss in late acute ABMR patients. Late acute ABMR patients are more frequently associated with nonadherence/suboptimal immunosuppression. There was also a low incidence of anti-HLA DSA positivity in late ABMR.

Leptospirosis during the COVID-19 pandemic: a case report

Since SARS-CoV-2 disease (COVID-19) has been labeled as a pandemic, it took the spotlight in the differential diagnosis for patients presenting with acute respiratory and systemic symptoms. Leptospirosis is one of the most common zoonoses in the world, yet it is mainly a disease of differential diagnosis for places that do not have it as an endemic. Due to the high burden of COVID-19 on the healthcare field, patients suffering from other infections may have been inadvertently neglected. COVID-19 infection can mimic other infectious diseases and can confuse physicians in their search for a confirmatory diagnosis. Nonetheless, it is very crucial to broaden the differential diagnosis and keep diseases like leptospirosis within the differential diagnosis despite its rarity, especially in patients presenting with unexplained systemic infectious symptoms. This is a unique case of a patient who presented with dyspnea, jaundice and change in urine color who was suspected to be COVID-19 positive. After a detailed investigation, the patient was diagnosed with leptospirosis instead of COVID-19 and was treated with plasmapheresis and antibiotics accordingly.

Emergency ABO-incompatible living donor liver transplantation in Wilson disease-induced acute liver failure

We report the clinical outcome of an emergency ABO incompatible-liver transplantation (LT) for an 8-year-old child with Wilson's disease-induced acute liver failure. The pretransplant anti-A antibody titer was 1:64, and hence he underwent three cycles of conventional plasma exchange as pretransplant liver supportive treatment for deranged coagulopathy and liver function followed by one cycle of immunoadsorption (IA) prior to LT. The posttransplant immunosuppression consisted of rituximab, tacrolimus, mycophenolate mofetil, and corticosteroid. The patient had anti-A isoagglutinin rebound with elevated aminotransferases levels from postoperative day 7 for which he was restarted on IA plasmapheresis, but antibody titers did not decrease. Hence, he was switched to conventional plasmapheresis (CP) with which anti-A antibody titers decreased. The total dose of rituximab (150 milligrams/square meter of body surface area) was given in two divided doses of 75 mg at D-1 and D + 8 which was much less than the dose conventionally advocated (375 milligrams/square meter of body surface area). He is clinically well with good graft function without rejection after 1 year of follow-up. This case illustrates that IA and CP in conjunction with adequate immunosuppression is a viable approach in emergency ABO-incompatible-LT in Wilson disease-induced acute liver failure.

A rare complication of IgA vasculitis: renal and intestinal ischemia successfully treated with plasmapheresis

BACKGROUND

IgA vasculitis (IgAV) is a multisystemic small vessel vasculitis and is the most common vasculitis in childhood. The characteristic findings of IgAV are palpable purpuric rash, abdominal pain, arthralgia or arthritis, and hematuria. Ischemic complications are very rare in IgAV. Thrombotic complications can be observed after a COVID-19 infection. Also in the presence of familial Mediterranean fever, IgAV may have an atypical or more severe course.

CASE

We present a case of IgAV complicated with renal infarction and intestinal ischemia. There was no recent or distant history of COVID-19 in the patient or family members, but the patient`s COVID-19 antibody was positive. In addition, MEFV gene analysis of the patient showed homozygous M694V mutation. The patient did not respond to enoxaparin, pulse methylprednisolone, intravenous immunoglobulin (IVIG), iloprost, and cyclophosphamide treatments. She was successfully treated with six sessions of plasmapheresis.

CONCLUSIONS

Plasmapheresis seems to be an effective treatment option in IgAV-related ischemic findings that do not respond to intensive immunosuppressive therapy.

Seronegative Atypical Anti-Glomerular Basement Membrane Glomerulonephritis Associated With Thrombotic Microangiopathy: Case Report and Literature Analysis

Anti-glomerular basement membrane (GBM) antibody nephritis is defined by linear immunofluorescence staining of GBM by immunoglobulin G (IgG), typically associated with GBM rupture, fibrinoid necrosis, and crescent formation. Clinically, the patients present with rapidly worsening renal function, often with hematuria. Typical renal pathologic findings include necrotizing and crescentic glomerulonephritis. In contrast, thrombotic microangiopathy (TMA) is characterized by microvascular thrombosis, which can also lead to acute kidney injury. Thrombotic microangiopathy is associated with some systemic diseases and has characteristic clinical features of microangiopathic hemolytic anemia, platelet consumption, and multiple organ failure. Anti-GBM nephritis associated with TMA has rarely been reported. We describe an unusual case of atypical anti-GBM disease without crescent formation or necrosis but with light microscopic and ultrastructural features consistent with endothelial cell injury and glomerular-limited TMA.

[Extracorporeal support treatment in severe malaria]

Malaria is a wide-spread disease in tropical areas. The severe form is characterized by organic involvement and/or hyperparasitaemia. Criteria for early monitoring in intensive care rooms are defined; without a timely and early treatment, severe malaria has a 100% mortality. Although the literature in these cases is not extensive, extracorporeal therapy used sequentially for hepatic and renal detoxification is a useful and safe tool that can be used in intensive care. We describe the case of a 36-year-old man with a diagnosis of severe malaria according to WHO criteria. He began treatment with intravenous artesunate and due to a torpid evolution, a sudden increase in bilirubinemia with encephalopathy, parameters of acute kidney injury and acute pulmonary edema, undergoes extracorporeal sequential treatment, coupled with plasma filtration adsorption, high-exchange plasmapheresis, and continuous hemodiafiltration with favorable evolution. This case shows that extracorporeal support in trained hands and in a timely manner is effective when organ failure evolves rapidly to achieve stability and provide necessary time for definitive treatment, in this case rapid action antimalarials until parasitemia becomes negative.

Atypical form of Goodpasture's disease

Goodpasture's disease and anti-glomerular basement membrane nephritis (anti-GBM nephritis) are rare autoimmune small vessel vasculitis predominantly affecting young men. Goodpasture's disease plays an important part in differential diagnosis of pulmonary - renal syndrome. The evidence of circulating autoantibodies, a typical histological appearance of the kidney biopsy with finding of the crescent glomerulonephritis and clinical presentation of nephritic syndrome play an important role in diagnosis. Our case report describes a case of a young male with anti-GBM nephritis that presents as rapidly progressive glomerulonephritis (RPGN) with progression to dialysis-dependent renal failure. The atypical sign of the case was development of nephrotic syndrome with volume-dependent hypertension. The case was complicated by heparin-induced thrombocytopenia. During combined immunosuppressive therapy with plasmapheresis, the condition of the patient has stabilized. However, renal function did not recover. This previously fatal disease has nowadays a very good survival rate because of immunosuppresion therapy, plasmapheresis and hemodialysis.

EFFICACY OF DOUBLE FILTRATION PLASMAPHERESIS TREATMENT IN ACUTE PANCREATITIS ASSOCIATED WITH SEVERE HYPERTRIGLYCERIDEMIA

Background and aim

Hypertriglyceridemia is one of the leading causes of acute pancreatitis and is associated with increased morbidity and mortality. Today the recommended treatment options are fasting, hydration, if necessary antibiotics and there is not a standard recommendation to decrease triglycerides rapidly. Double Fıltratıon Plasmapheresis (DFPP) may be an option to decrease triglycerides rapidly but its effect on the disease course is unknown.

Method

In the present study, we present results of four acute pancreatitis cases associated with hypertriglyceridemia treated with DFPP. All of the patients were diagnosed as acute pancreatitis at emergency room and no complications were observed in sessions. A 76.3% reduction in triglyceride levels was observed in one or two treatment sessions.

Results and conclusion

DFPP is an effective and safe option to decrease triglyceride levels rapidly but further research is needed to show the effect on mortality and morbidity.

Rheopheresis Performed in Hemodialysis Patients Targets Endothelium and Has an Acute Anti-Inflammatory Effect

Background: Rheopheresis is a double-filtration plasmapheresis that removes a defined spectrum of high-molecular-weight proteins to lower plasma viscosity and improves microcirculation disorders. This technique can be performed in hemodialysis (HD) patients with severe microischemia. Interestingly, some studies showed that rheopheresis sessions improve endothelial function. Methods: Our study evaluated the inflammatory and endothelial biomarker evolution in 23 HD patients treated or not with rheopheresis. A p value ≤ 0.001 was considered statistically significant. Results: Thirteen HD patients treated by rheopheresis either for a severe peripheral arterial disease (N = 8) or calciphylaxis (N = 5) were analyzed. Ten control HD patients were also included in order to avoid any misinterpretation of the rheopheresis effects in regard to the HD circuit. In the HD group without rheopheresis, the circulating endothelial adhesion molecules, cytokines, angiogenic factor concentrations, and circulating levels were not modified. In the HD group with rheopheresis, the circulating endothelial adhesion molecules (sVCAM-1, sP-selectin, and sE-selectin) experienced a significant reduction, except sICAM-1. Among the pro-inflammatory cytokines, TNF-α was significantly reduced by 32.6% [(−42.2)−(−22.5)] (p < 0.0001), while the anti-inflammatory cytokine IL-10 increased by 674% (306−1299) (p < 0.0001). Among the angiogenic factors, only sEndoglin experienced a significant reduction. The CEC level trended to increase from 13 (3−33) cells/mL to 43 (8−140) cells/mL (p = 0.002). We did not observe any difference on the pre-session values of the molecules of interest between the first rheopheresis session and the last rheopheresis session. Conclusion: Rheopheresis immediately modified the inflammation balance and the endothelial injury biomarkers. Further studies are needed to understand the mechanisms underlying these biological observations.

Hämoperfusion und Plasmapherese auf der Intensivstation

Neben Nierenersatzverfahren werden auf der Intensivstation mehrere andere extrakorporale Verfahren eingesetzt. In den 1970er- bis 2000er-Jahren stand die Hämoperfusion mit Aktivkohlekapseln zur Entfernung von Toxinen im Vordergrund. Dies ist mittlerweile aufgrund der effektiven Dialyseverfahren, die im Vergiftungsfall auch stark proteingebundene Toxine entfernen, fast bedeutungslos geworden. Vor 10 Jahren erlebte ein Zytokinadsorber die Markteinführung, der darauf gerichtet ist, den „Zytokinsturm“ zu überstehen. Dieser erfreut sich trotz ernüchternder Daten aus prospektiven, randomisierten, kontrollierten Studien wachsender Beliebtheit. Ein gänzlich anderes Therapiekonzept ist der biomimetische Pathogenadsorber, der Bakterien, Viren und Pilze durch Bindung an immobilisiertes Heparin aus dem Blutstrom entfernt. Ob sich diese schnelle Reduktion der Pathogenlast in eine Verbesserung klinisch relevanter Endpunkte übersetzt, ist unklar, da hier prospektive, randomisierte und kontrollierte Studien gänzlich fehlen. Für ein sehr altes Verfahren, nämlich die Plasmapherese, werden wir für die Frühphase der Sepsis bis zum Jahr 2025/2026 Ergebnisse aus 2 großen randomisierten, kontrollierten Studien aus Europa und Kanada erhalten. Neben der Entfernung von Zytokinen erhofft man sich durch die Verwendung von Frischplasma als Austauschflüssigkeit auch das Wiederauffüllen reduzierter protektiver Faktoren wie Angiopoietin 1, ADAMTS13 („a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13“) und Protein C. Alle genannten Verfahren funktionieren nicht nur unterschiedlich, sondern werden auch zu unterschiedlichen Zeitpunkten der Blutstrominfektion/Sepsis eingesetzt.

Two case reports of skin vasculitis following the COVID-19 immunization

The coronavirus 2019 (COVID-19) disease is now responsible for one of the most challenging and concerning pandemics. Since December 2020, the world has had access to COVID-19 prophylaxis; thus, we encounter adverse events from vaccination more often due to the vast vaccination range. We present two case reports of difficult-to-treat skin vasculitis due to COVID-19 vaccination that were successfully treated in a tertiary-level university hospital. When encountering systemic treatment, resistant skin vasculitis plasmapheresis could be a choice of treatment.

Risk of tuberculosis among renal transplant recipients receiving rituximab therapy

BACKGROUND

Rituximab is an anti-CD 20 agent used widely in renal transplant recipients. Its use is associated with various infections; however, its association with tuberculosis (TB) is not well established and has not been studied in post renal transplantation patients.

METHODS

This is a single-center, retrospective analysis of 56 renal transplant recipients who received rituximab as a part of desensitization protocol or as rescue therapy for rejections and 287 post-renal transplant patients who did not receive rituximab during the study period from January 2013 to June 2017. The association between use of rituximab and occurance of TB was studied. Other factors associated with TB were also investigated.

RESULTS

Baseline characteristics were similar in both the groups. Mean time for occurrence of TB was 18.4 ± 10.6 months after renal transplantation. Rituximab use was not significantly associated with TB or any other infection. Higher number of rejection episodes (60% vs. 32.72%, p = .029) was the only factor associated with greater incidence of TB. However, no specific type of rejection was associated with TB. Use of plasmapheresis in post-transplant period for treatment of humoral rejections was associated with significantly higher incidence of TB (33.33% vs. 13.41%, p = .031); however, when pre-transplant plasmapheresis was also considered, there was no significant difference. The choice of induction agent was not associated with higher incidence of TB.

CONCLUSION

Use of rituximab is not associated with higher incidence of TB when compared to other immunosuppressive agents. Routine screening and prophylaxis may not be advisable, especially in a country like India with high prevalence of TB, as it will further delay transplantation and may adversely affect the outcome of the patients.

Thrombotic Thrombocytopenic Purpura Treated Successfully in a COVID-19 Patient Having a Computed Tomography Severity Score of 22/25

We present a case of a 50-year-old female who came to us with chief complaints of breathlessness, general weakness, and cough. She tested positive for coronavirus disease 2019 (COVID-19) on testing with Reverse Transcription Polymerase Chain Reaction (RT-PCR). She had high resolution computed tomography (HRCT) thorax score of 22/25. On investigation, she had thrombocytopenia with schistocytosis on the peripheral smear and evidence of acute kidney injury. She was diagnosed with thrombotic thrombocytopenic purpura (TTP) and was treated with oral prednisone, plasma exchange, and remdesivir. There was an improvement in clinical as well as biochemical parameters such as lactate dehydrogenase, haemoglobin, and platelet counts. This case report highlights TTP that may be a serious complication in COVID-19 patients, especially with a CT severity score of 22/25. Early diagnosis and intervention can lead to a positive outcome.

Guillain-Barré syndrome after COVID-19 vaccination: report of two cases from Vietnam

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization in March 2020 and since then it has spread to almost every country around the world. Vaccines against COVID-19 are considered an essential measure to curb this pandemic. However, side effects, including local and systemic reactions, after administering the COVID-19 vaccine have been defined, and some side effects have been reported. We present two cases of Guillain-Barré Syndrome (GBS) after receiving the ChAdOx1 nCoV-19 vaccine (Oxford- AstraZeneca). Both cases were admitted to the 108 Military Central Hospital, Vietnam, and received plasmapheresis therapy with satisfactory recovery after treatment.

Comparison of outcomes and costs of extracorporeal blood purification therapies in critically ill COVID-19 patients

INTRODUCTION

Plasmapheresis and hemoperfusion are used against cytokine release syndrome in COVID-19. This study aims to compare their outcomes, costs, and side-effects.

METHODS

Survival, costs and side-effects were compared in intensive care unit (ICU) patients receiving plasmapheresis (n = 49), hemoperfusion (n = 20), or none (n = 107), followed until death or discharge.

RESULTS

Plasmapheresis survival time was higher than hemoperfusion or controls (HR = 0.764, p = 0.397 and HR = 0.483, p = 0.002, respectively), although the latter diminished after controlling for age and disease severity (p = 0.979). There was no significant difference in ICU costs for plasmapheresis and hemoperfusion (p = 0.738) while both costed more than controls (both p < 0.001). Hypocalcemia and thrombocytopenia incidence did not differ between two groups (p = 0.124 and p = 0.389, respectively) while being higher than controls in plasmapheresis (both p < 0.001) and hemoperfusion (p < 0.001 and p = 0.056, respectively).

CONCLUSION

Plasmapheresis and hemoperfusion do not differ significantly in patient survival, ICU costs and side-effects with a higher incidence of hypocalcemia and thrombocytopenia compared witcontrols.

Plasmapheresis for a Patient with Catatonia and Systemic Lupus Erythematosus: A Case Report and Literature Review

Neuropsychiatric systemic lupus erythematous (NPSLE) encompasses various psychiatric and neurological manifestations that develop in patients with systemic lupus erythematous (SLE), secondary to the involvement of the central nervous system (CNS). Although neuropsychiatric manifestations are commonly described in NPSLE, catatonia has been less frequently reported in patients with SLE. The roles of benzodiazepines (BZDs), immunosuppression, therapeutic plasma exchange (TPE), and electroconvulsive therapy (ECT) have all been reported in the management of catatonia. Furthermore, another research reported that catatonic symptoms associated with NPSLE were considerably improved by TPE. We, herein, report a case of catatonia in a patient with newly diagnosed NPSLE who exhibited a favorable prognosis through the early initiation of systemic immunosuppressants and TPE. Furthermore, we have reviewed the literature on the role of medication and plasmapheresis (PP), or TPE, in the treatment of catatonia that is associated with SLE.

Plasmapheresis as an Alternative Treatment of Hypertriglyceridemia-Induced Pancreatitis: A Case Report

Hypertriglyceridemia-induced pancreatitis is a relatively common form of acute pancreatitis that may represent up to 10% of all etiologies of this condition. Due to its specific pathogenic mechanisms related to high serum triglyceride levels, different treatment options have been proposed, including insulin perfusion, heparin perfusion, and plasmapheresis. Although the superiority of plasmapheresis in this clinical setting has not been demonstrated in randomized clinical trials, many centers have reported its effectiveness and considered this as a possible alternative according to the current guidelines. We report a case of a young patient diagnosed with hypertriglyceridemia-induced pancreatitis that was successfully treated with plasmapheresis. Since complications associated with plasmapheresis are rare and other therapeutic options may not be so effective or safe, we believe that this should be a valid alternative treatment that may be offered to these patients. More studies are still needed to further evaluate its effectiveness and to elucidate if there is a subset of patients in whom treatment with plasmapheresis may be more beneficial.

Treating Hypertriglyceridemia-Induced Pancreatitis With Intravenous Insulin and Plasmapheresis

Hypertriglyceridemic pancreatitis (HTGP) is well-known but it is extremely rare, especially in younger patients. The main treatment modalities for HTGP are apheresis and intravenous insulin. However, apheresis in severe HTGP is not well established and the efficacy of the treatment is lacking. Herein, we discuss a case of a 17-year-old female patient with no significant past medical history who initially presented to the emergency department with severe diabetic ketoacidosis (DKA) and was intubated due to severe metabolic acidosis and impending respiratory failure on arrival. Further investigation showed evidence of HTGP. Initially, her condition did not improve with intravenous insulin. However, a course of apheresis along with supportive care improved her condition drastically. Hence, this is a case report which showed the efficacy of concomitant use of insulin infusion and plasmapheresis in regard to treating HTGP. Outcomes of HTGP based on different treatment modalities are discussed in this literature as well. However, to date, there are no randomized studies to draw a solid treatment algorithm, thus further research on the most efficient treatment regimes is required for the management of HTGP.

Therapeutic plasma exchange for myasthenia gravis, Guillain-Barre syndrome, and other immune-mediated neurological diseases, over a 40-year experience

BACKGROUND

Therapeutic plasma exchange (TPE) was first used in neurology in the 1980s for myasthenia gravis (MG) and Guillain-Barré syndrome (GBS). Indications have since grown. Fear of complications with this treatment modality limit its use.

RESEARCH DESIGN & METHODS

A study of patients undergoing TPE for neurological diseases (1981-2020) in a University Hospital in Madrid, Spain. Clinical indications, complications, procedure number, apheresis technique and replacement fluids were prospectively recorded and retrospectively analyzed. Historical trends were studied.

RESULTS

 159 patients (48.69 ±18.15 years, 54.3% females) underwent TPE using central-venous catheter and replacement fluid albumin. We performed 1207 procedures over 189 cycles (6.4 ±3.8 procedures/cycle). Most patients underwent TPE for category I-II indications, mainly GBS and MG (77.7%). Complication rate was low (3.9% procedures), mostly hypotensive/vasovagal reactions (55.3%) and vascular access-related complications (38.3%). Most were mild-moderate (92.9%), permitting TPE completion, and somewhat more frequent during the first procedure (38.3%) and after periods of little TPE use. GBS patients were more prone to complications than MG patients (6.5% vs. 1.2%,p<0.001) mainly hypotensive/vasovagal reactions (3.7% vs. 1.0%,p=0.008).

CONCLUSIONS

TPE is well-tolerated with low complication rate (<4% procedures), mainly hypotensive/vasovagal reactions. Patients with GBS seem more prone to them than MG patients. Acquaintance with this technique seems necessary.

Identification of factors affecting outcomes in patients with Guillain Barre syndrome

Background

Guillain Barre syndrome (GBS) is a rare autoimmune neurological disorder resulting in variable clinical course and outcome. Various factors such as age, symptoms and disease form that influence the outcome of GBS have been previously studied.

Aim

This study aimed at identifying factors affecting the outcomes in patients with GBS.

Methods

A retrospective observational study was conducted on GBS (ICD-G61.0) patients admitted to the hospital between 2014 and 2019. Patient information on demographics, medical and medication history, laboratory parameters, electrophysiological data, type of GBS and therapy received were retrieved from medical records. Univariate and multivariate analysis were conducted to identify factors associated with outcome (improved and not improved) and calculate odds ratio (OR).

Results

A total of 212 GBS patients were included in the study, of which 67% were males and the mean age was 39.9±20.1 years. 168 (79%) patients showed improvement whereas the remaining 44(21%) did not show improvement. Patients with hypertension (OR=4.512; CI=1.309-15.556, p=0.017), alcoholics (OR=5.148; CI=1.234-21.472, p=0.025), sepsis (OR= 9.139; CI=1.102-75.760, p=0.040) and cardiac arrest (OR=17.495; CI=1.249-245.027, p=0.034) were associated with risk of no improvement. Whereas those treated with IVIgG plus Physiotherapy/Occupational therapy (OR=0.062; CI=0.016-0.242, p=0.001) and Plasmapheresis plus Physiotherapy/Occupational therapy (OR=0.007; CI=0.000-0.147, p=0.001) were associated with improvement.

Conclusion

Understanding these factors help to further give a more directed and focused management to improve the condition in patients who are at risk of poor outcome. Further follow-up studies could be done to determine and manage the residual disabilities associated with GBS to improve patient's quality of life.