Thrombocytopenia-associated multiorgan failure occurring in an infant at the onset of type 1 diabetes successfully treated with fresh frozen plasma

Immune thrombotic thrombocytopenic purpura and diabetic ketoacidosis: a case report and literature review

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is an uncommon and life-threatening disorder caused by a deficiency of ADAMTS-13, and eventually leads to microangiopathic hemolytic anemia, severe thrombocytopenia, and organ damages. Acute TTP events could be triggered by infections, or inflammations in the context of ADAMTS-13 deficiency. Recently, several case reports have indicated an association between diabetic ketoacidosis (DKA) and TTP. Here, we present a case with the concomitant presentation of DKA and TTP.

CASE PRESENTATION

A 37-year-old male with diabetes mellitus presented with typical symptoms of diabetic ketoacidosis. He was managed with an insulin pump and intravenous fluids. However, he developed seizure and progressed to coma, his rapidly deteriorating condition necessitated continuous renal replacement therapy, intubation, and inotropic support. Laboratory data indicated hemolytic anemia and thrombocytopenia, and a blood smear revealed schistocytes. The PLASMIC score was 5, and ADAMTS-13 activity was 2%. The patient was diagnosed with TTP and treated with therapeutic plasma exchange, steroids, and rituximab. His platelet count stabilized above 150,000/µL, and ADAMTS-13 activity progressively improved.

CONCLUSIONS

This case report emphasizes the concurrence of DKA and iTTP, presenting the rare complication of acute renal failure in TTP. TTP is a rare and serious disease that requires prompt recognition and management. Concurrent conditions should be considered when calculating prediction scores such as the PLASMIC and French scores.

Successful plasma exchange in a 34-year-old woman with diabetic ketoacidosis and a thrombotic microangiopathy

Thrombotic microangiopathy (TMA) associated with diabetic ketoacidosis (DKA) is a rare complication reported in the pediatric setting. We report a case of an adult patient with new-onset DM, DKA, and TMA who was treated successfully with therapeutic plasma exchange (TPE). The patient underwent five procedures and experienced quick recovery in her platelet count and a near-normalization of her LDH. Within 3 days, ADAMTS13 activity was reported at 40.7% (>66.8%). After a protracted hospital course, mostly focused on treating the patient's bilateral hemorrhagic chemosis, the patient was discharged on hospital day 30. TMA is associated with a spectrum of diseases such as TTP and sepsis but, to our knowledge, it has not been reported in the setting of DKA in an adult patient. Evidence supports that metabolic alterations associated with DKA and its treatment disrupt basal hemostatic mechanisms and promote a thrombotic state. Although ADAMTS13 activity was only moderately decreased, our patient responded rapidly to TPE, with a striking increase and stabilization of her PLT count that was durable beyond discharge. As reported recently, patients who have TMA with ADAMTS13 activity levels >10% have a range of diagnoses, presentations, and outcomes. Although the underlying microangiopathic process is incompletely understood, these patients may respond well to TPE, as was seen in this case.

Thrombocytopenia-associated multi-organ failure secondary to hyperglycemic, hyperosmolar non-ketotic syndrome: A case report

Thrombocytopenia associated multi-organ failure (TAMOF) is a clinical syndrome with features of new onset thrombocytopenia, increased lactate dehydrogenase, and multi-organ failure in critically ill patients. TAMOF can be the initial presentation of an underlying disease process or can develop during the course of illness either during the hospital stay. TAMOF has a high mortality rate if not treated; therefore, early detection is critical. TAMOF has been rarely reported in diabetic ketoacidosis. We are describing the first case of a patient diagnosed with hyperglycemic, hyperosmolar non-ketotic syndrome who developed TAMOF on the third day of his hospital course. In addition to supportive care in the intensive care unit the patient received serial therapeutic plasma exchanges and improved quickly after treatment. Early diagnosis and treatment of TAMOF decreases morbidity and mortality.

Thrombocytopenia-associated multiorgan failure occurring in an infant at the onset of type 1 diabetes successfully treated with fresh frozen plasma

TAMOF is a devastating microangiopathy that can occur in association with the new onset of T1DM, and should be considered with the onset of thrombocytopenia, renal failure, and raised LDH. Treatment with fresh frozen plasma should be considered as a first‐line option in such cases prior to plasma exchange.