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Choi M, Butler E, Clarke A, Girard LP, Gibson P, Skeith L. Managing pregnancy-associated clinical emergencies in systemic lupus erythematosus: a case-based approach. Expert Rev Clin Immunol 2019; 16:5-22. [PMID: 31791152 DOI: 10.1080/1744666x.2019.1699057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE)-related thrombocytopenia during pregnancy and the postpartum period have been associated with adverse pregnancy outcomes and perinatal complications. In this case report, we present two SLE patients with thrombocytopenia emergencies secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and thrombotic thrombocytopenic purpura (TTP).Areas covered: The first case involved a 26-year-old woman, G1P0 at 26 weeks gestation (GA), with high-titer antiphospholipid antibodies (aPL) (positive lupus anticoagulant, anti-beta 2 glycoprotein-1 (aβ2GP1), anti-cardiolipin) and non-criteria aPL to phosphatidylserine/prothrombin complex and anti-domain 1 β2GP1. This case highlights the risks associated with aPL in pregnancy, considers management issues relating to anticoagulation during pregnancy and highlights the importance of maintaining a high index of suspicion for diagnosis of HELLP in SLE patients. The second case was a 36-year-old female, G3P2 at 32 weeks GA, with class III lupus nephritis (LN) who developed severe pre-eclampsia, which included mild thrombocytopenia. This case illustrates the challenges in identifying and differentiating between three pregnancy emergencies that can be seen in SLE patients (pre-eclampsia, LN, and TTP) and presents the management of TTP in peripartum SLE.Expert opinion: These two cases remind us of the importance of timely diagnosis and management of thrombocytopenia in this population.
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Affiliation(s)
- May Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin Butler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Louis Phillipe Girard
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Gibson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Delgado-García G, Cámara-Lemarroy C, Infante-Valenzuela A, Colunga-Pedraza P, Alarcón-Galván G, Armenta-González A, Villarreal-Velázquez HJ. Pure lupus podocytopathy first presenting as thrombotic thrombocytopenic purpura-like syndrome. Clin Rheumatol 2015; 35:2131-2136. [PMID: 26384822 DOI: 10.1007/s10067-015-3069-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 08/24/2015] [Accepted: 08/30/2015] [Indexed: 12/27/2022]
Abstract
Lupus podocytopathy (LP) is an uncommon proteinuric disorder in the spectrum of lupus nephropathy. Its histological features are similar to those described in minimal change disease (MCD) with or without mesangial immune deposits. Although infrequent, a close relationship between systemic lupus erythematosus (SLE) and thrombotic thrombocytopenic purpura (TTP) is well accepted. Proteinuria in the setting of SLE has previously been associated with the development of TTP-like syndrome. As far as we know, LP first presenting as a TTP-like syndrome has never been reported. Here, we describe the case of a previously healthy 45-year-old woman who developed simultaneously these two conditions and then we briefly review the literature on the topic, emphasizing the previous cases of concurrent initial diagnosis of both SLE and MCD (n = 7) and SLE and TTP (n = 72). In conclusion, renal biopsy is central to the management of SLE patients with nephrotic syndrome. Furthermore, in a SLE patient with anemia and thrombocytopenia, TTP should be part of the differential diagnosis, even when no schistocytes were detected in peripheral blood smear.
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Affiliation(s)
- Guillermo Delgado-García
- Department of Internal Medicine, University Hospital, Autonomous University of Nuevo León, Madero y Gonzalitos s/n, Col. Mitras Centro, C.P. 64460, Monterrey, Nuevo León, Mexico.
| | - Carlos Cámara-Lemarroy
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Adrián Infante-Valenzuela
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Perla Colunga-Pedraza
- Division of Hematology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Gabriela Alarcón-Galván
- Service of Anatomic Pathology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Arian Armenta-González
- Division of Rheumatology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
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