1
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Zhang Z, Yang S, Wang X. Schistocyte detection in artificial intelligence age. Int J Lab Hematol 2024; 46:427-433. [PMID: 38472155 DOI: 10.1111/ijlh.14260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Schistocytes are fragmented red blood cells produced as a result of mechanical damage to erythrocytes, usually due to microangiopathic thrombotic diseases or mechanical factors. The early laboratory detection of schistocytes has a critical impact on the timely diagnosis, effective treatment, and positive prognosis of diseases such as thrombocytopenic purpura and hemolytic uremic syndrome. Due to the rapid development of science and technology, laboratory hematology has also advanced. The accuracy and efficiency of tests performed by fully automated hematology analyzers and fully automated morphology analyzers have been considerably improved. In recent years, substantial improvements in computing power and machine learning (ML) algorithm development have dramatically extended the limits of the potential of autonomous machines. The rapid development of machine learning and artificial intelligence (AI) has led to the iteration and upgrade of automated detection of schistocytes. However, along with significantly facilitated operation processes, AI has brought challenges. This review summarizes the progress in laboratory schistocyte detection, the relationship between schistocytes and clinical diseases, and the progress of AI in the detection of schistocytes. In addition, current challenges and possible solutions are discussed, as well as the great potential of AI techniques for schistocyte testing in peripheral blood.
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Affiliation(s)
- Zeng Zhang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Zhejiang, Hangzhou, China
| | - Su Yang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Zhejiang, Hangzhou, China
| | - Xiuhong Wang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Zhejiang, Hangzhou, China
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2
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Howick V JF, Harmon DM, McBane RD. 44-Year-Old Woman With Cough and Shortness of Breath. Mayo Clin Proc 2023; 98:1557-1563. [PMID: 37793730 DOI: 10.1016/j.mayocp.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 10/06/2023]
Affiliation(s)
- James F Howick V
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David M Harmon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Robert D McBane
- Advisor to residents and Consultant in Vascular Cardiology, Mayo Clinic, Rochester, MN.
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3
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Foy BH, Stefely JA, Bendapudi PK, Hasserjian RP, Al-Samkari H, Louissaint A, Fitzpatrick MJ, Hutchison B, Mow C, Collins J, Patel HR, Patel CH, Patel N, Ho SN, Kaufman RM, Dzik WH, Higgins JM, Makar RS. Computer vision quantitation of erythrocyte shape abnormalities provides diagnostic, prognostic, and mechanistic insight. Blood Adv 2023; 7:4621-4630. [PMID: 37146262 PMCID: PMC10448422 DOI: 10.1182/bloodadvances.2022008967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 05/07/2023] Open
Abstract
Examination of red blood cell (RBC) morphology in peripheral blood smears can help diagnose hematologic diseases, even in resource-limited settings, but this analysis remains subjective and semiquantitative with low throughput. Prior attempts to develop automated tools have been hampered by their poor reproducibility and limited clinical validation. Here, we present a novel, open-source machine-learning approach (denoted as RBC-diff) to quantify abnormal RBCs in peripheral smear images and generate an RBC morphology differential. RBC-diff cell counts showed high accuracy for single-cell classification (mean AUC, 0.93) and quantitation across smears (mean R2, 0.76 compared with experts, interexperts R2, 0.75). RBC-diff counts were concordant with the clinical morphology grading for 300 000+ images and recovered the expected pathophysiologic signals in diverse clinical cohorts. Criteria using RBC-diff counts distinguished thrombotic thrombocytopenic purpura and hemolytic uremic syndrome from other thrombotic microangiopathies, providing greater specificity than clinical morphology grading (72% vs 41%; P < .001) while maintaining high sensitivity (94% to 100%). Elevated RBC-diff schistocyte counts were associated with increased 6-month all-cause mortality in a cohort of 58 950 inpatients (9.5% mortality for schist. >1%, vs 4.7% for schist; <0.5%; P < .001) after controlling for comorbidities, demographics, clinical morphology grading, and blood count indices. RBC-diff also enabled the estimation of single-cell volume-morphology distributions, providing insight into the influence of morphology on routine blood count measures. Our codebase and expert-annotated images are included here to spur further advancement. These results illustrate that computer vision can enable rapid and accurate quantitation of RBC morphology, which may provide value in both clinical and research contexts.
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Affiliation(s)
- Brody H. Foy
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Systems Biology, Harvard Medical School, Boston, MA
| | - Jonathan A. Stefely
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Blood Transfusion Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Pavan K. Bendapudi
- Blood Transfusion Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robert P. Hasserjian
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Abner Louissaint
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Megan J. Fitzpatrick
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Bailey Hutchison
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher Mow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Mass General Brigham Enterprise Research IS, Boston, MA
| | - Julia Collins
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hasmukh R. Patel
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Chhaya H. Patel
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nikita Patel
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Samantha N. Ho
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard M. Kaufman
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Walter H. Dzik
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Blood Transfusion Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John M. Higgins
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Systems Biology, Harvard Medical School, Boston, MA
| | - Robert S. Makar
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Blood Transfusion Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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4
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Venier LM, Patriquin CJ, Warkentin TE. Acute thrombocytopenia suggesting thrombotic microangiopathy. Am J Hematol 2022; 97:659-665. [PMID: 35253925 DOI: 10.1002/ajh.26515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Laura M. Venier
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Theodore E. Warkentin
- Department of Medicine Michael G. DeGroote School of Medicine, McMaster University Hamilton Ontario Canada
- Department of Pathology & Molecular Medicine Michael G. DeGroote School of Medicine, McMaster University Hamilton Ontario Canada
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Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel) 2022; 14:toxins14010057. [PMID: 35051033 PMCID: PMC8778654 DOI: 10.3390/toxins14010057] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.
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Bhattarai A, Shah S, Bagherieh S, Mirmosayyeb O, Thapa S, Paudel S, Gyawali P, Khanal P. Endothelium, Platelets, and Coagulation Factors as the Three Vital Components for Diagnosing Bleeding Disorders: A Simplified Perspective with Clinical Relevance. Int J Clin Pract 2022; 2022:5369001. [PMID: 36101812 PMCID: PMC9440837 DOI: 10.1155/2022/5369001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/31/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
Bleeding disorders are a major group of hematological disorders, which are highly prevalent in the world. Excessive bleeding can result in serious consequences including hypoperfusion and cardiac arrest. The body has its selfmechanism to control excessive bleeding which is termed hemostasis. Hemostasis is achieved in two major steps, the formation of the primary and secondary hemostatic plugs. Endothelium, platelets, and coagulation factors are three components involved in hemostasis. Endothelium and platelets have a major role in forming the primary hemostatic plug. Consequently, the first step in investigating a bleeding disorder is platelet count. Despite normal platelet count, abnormality in the primary hemostatic plug may arise due to functional defects of the platelets including adhesion, activation, and aggregation. Von Willebrand disease (VWD) is an endothelial defect and the most prevalent inherited defect in coagulation. Abnormalities in the secondary hemostatic plug are largely due to coagulation factor deficiencies, and, to a lesser extent, the presence of inhibitors. Techniques involving viscoelastics have been aiding in rapid diagnosis and are useful in point-of-care testing. This article discusses the investigation of bleeding disorders from the perspective of the endothelium, platelet, and coagulation factor physiology. These three components should be properly investigated to achieve the definitive diagnosis of bleeding disorders.
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Affiliation(s)
- Abhinav Bhattarai
- Institute of Medicine, Tribhuvan University, Maharajgunj 44600, Nepal
| | - Sangam Shah
- Institute of Medicine, Tribhuvan University, Maharajgunj 44600, Nepal
| | | | | | - Sangharsha Thapa
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University, Buffalo, State University of NY, Buffalo, NY, USA
| | - Sandip Paudel
- Institute of Medicine, Tribhuvan University, Maharajgunj 44600, Nepal
| | - Pawan Gyawali
- Institute of Medicine, Tribhuvan University, Maharajgunj 44600, Nepal
| | - Pitambar Khanal
- Institute of Medicine, Tribhuvan University, Maharajgunj 44600, Nepal
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Ling L, Huang X, Liu C, Liao J, Zhou J. Monitoring coagulation-fibrinolysis activation prompted timely diagnosis of hemophagocytic lymphohistiocytosis-related disseminated intravascular coagulation. Thromb J 2021; 19:82. [PMID: 34736467 PMCID: PMC8569956 DOI: 10.1186/s12959-021-00338-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/26/2021] [Indexed: 02/08/2023] Open
Abstract
Background Timely diagnosis of disseminated intravascular coagulation (DIC) in hemophagocytic lymphohistiocytosis (HLH) patients is crucial but challenging, as HLH interferes with the results of the laboratory tests included in the DIC score system. Case presentation Here, we reported a case of lymphoma-associated HLH, in which coagulation-fibrinolysis activation /inhibition markers (TAT, tPAIC, and PIC), prompted timely diagnosis of early stage DIC (initial phase of microvascular thrombosis, yet non-overt), prior to the development of organ failures and/or bleedings. Conclusions This report highlights the importance of the implementation of new biomarkers (such as TAT, tPAIC, and PIC), into the diagnostic work-up for coagulation disorders. These biomarkers are directly suggestive of microthrombus formation, therefore they can be of paramount importance in diagnosing DIC with complicated etiologies, such as hematological diseases-related DIC. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00338-y.
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Affiliation(s)
- Liqin Ling
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Sichuan, 610041, Chengdu, China
| | - Xunbei Huang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Sichuan, 610041, Chengdu, China
| | - Chaonan Liu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Sichuan, 610041, Chengdu, China
| | - Juan Liao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Sichuan, 610041, Chengdu, China
| | - Jing Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Sichuan, 610041, Chengdu, China.
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8
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Molenaar FM, Silvestre P. Clinical approach to colic and collapse in an Asian elephant (
Elephas maximus
) with
Salmonella saintpaul
septicaemia and subsequent ileus. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fieke M. Molenaar
- ZSL Whipsnade Zoo, Wildlife Health Services part of the Zoological Society of London Regents Park London United Kingdom
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9
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Complement C5 inhibition protects against hemolytic anemia and acute kidney injury in anthrax peptidoglycan-induced sepsis in baboons. Proc Natl Acad Sci U S A 2021; 118:2104347118. [PMID: 34507997 DOI: 10.1073/pnas.2104347118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 01/20/2023] Open
Abstract
Late-stage anthrax infections are characterized by dysregulated immune responses and hematogenous spread of Bacillus anthracis, leading to extreme bacteremia, sepsis, multiple organ failure, and, ultimately, death. Despite the bacterium being nonhemolytic, some fulminant anthrax patients develop a secondary atypical hemolytic uremic syndrome (aHUS) through unknown mechanisms. We recapitulated the pathology in baboons challenged with cell wall peptidoglycan (PGN), a polymeric, pathogen-associated molecular pattern responsible for the hemostatic dysregulation in anthrax sepsis. Similar to aHUS anthrax patients, PGN induces an initial hematocrit elevation followed by progressive hemolytic anemia and associated renal failure. Etiologically, PGN induces erythrolysis through direct excessive activation of all three complement pathways. Blunting terminal complement activation with a C5 neutralizing peptide prevented the progressive deposition of membrane attack complexes on red blood cells (RBC) and subsequent intravascular hemolysis, heme cytotoxicity, and acute kidney injury. Importantly, C5 neutralization did not prevent immune recognition of PGN and shifted the systemic inflammatory responses, consistent with improved survival in sepsis. Whereas PGN-induced hemostatic dysregulation was unchanged, C5 inhibition augmented fibrinolysis and improved the thromboischemic resolution. Overall, our study identifies PGN-driven complement activation as the pathologic mechanism underlying hemolytic anemia in anthrax and likely other gram-positive infections in which PGN is abundantly represented. Neutralization of terminal complement reactions reduces the hemolytic uremic pathology induced by PGN and could alleviate heme cytotoxicity and its associated kidney failure in gram-positive infections.
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Zini G, d'Onofrio G, Erber WN, Lee SH, Nagai Y, Basak GW, Lesesve JF. 2021 update of the 2012 ICSH Recommendations for identification, diagnostic value, and quantitation of schistocytes: Impact and revisions. Int J Lab Hematol 2021; 43:1264-1271. [PMID: 34431220 DOI: 10.1111/ijlh.13682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022]
Abstract
In 2012, the International Council for Standardization in Hematology (ICSH) published recommendations for the identification, quantitation, and diagnostic value of schistocytes. In the present review, the impact of these recommendations is evaluated. This work is based on citations in peer-reviewed papers published since 2012. The first 2012 ICSH Recommendations have also been revised to incorporate newly published data in the literature and current best laboratory practice. Recommended reference ranges have been proposed for healthy adults and full-term neonates of 1% or less schistocytes. More than 1% of morphologically identified schistocytes on the blood film are considered suspicious for thrombotic microangiopathy. For preterm infants, a normal level of 5% or less is recommended. The fragment red cell count (FRC) generated by some automated hematological analyzers provides a valuable screening tool for the presence of schistocytes. Specifically, the absence of FRCs can be used as a valuable parameter to exclude the presence of schistocytes on the blood film. The validity and usefulness of microscope schistocytes and automated FRCs, respectively, are discussed in the context of the laboratory diagnostic tests used for thrombotic microangiopathies.
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Affiliation(s)
- Gina Zini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Wendy N Erber
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Szu-Hee Lee
- St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Yutaka Nagai
- Faculty of Clinical Laboratory, Kansai University of Health Sciences, Osaka, Japan
| | - Grzegorz W Basak
- Department of Haematology, Transplantation and Internal Medicine, The Medical University of Warsaw, Warsaw, Poland.,Transplant Complications Working Party, European Society for Blood and Marrow Transplantation, Warsaw, Poland
| | - Jean-François Lesesve
- Service d'Hématologie Biologique, Centre Hospitalier Régional Universitaire de Nancy, and U1256 INSERM, Université de Lorraine, Lorraine, France
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11
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Smock KJ. ADAMTS13 testing update: Focus on laboratory aspects of difficult thrombotic thrombocytopenic purpura diagnoses and effects of new therapies. Int J Lab Hematol 2021; 43 Suppl 1:103-108. [PMID: 34288437 DOI: 10.1111/ijlh.13557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 02/05/2023]
Abstract
TTP is a life-threatening disorder diagnosed using a combination of clinical information and laboratory results. ADAMTS13 activity and antibody testing represent a major advance in the field, but results can sometimes be difficult to interpret due to technical aspects of the tests and characteristics of the causative antibodies in acquired TTP. Genetic testing for ADAMTS13 mutations is also now available to assist with the diagnosis of inherited TTP. This review will focus on ADAMTS13 testing and will highlight patient and laboratory aspects that can lead to diagnostic difficulty. The effects of TTP therapies on test results will also be discussed.
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Affiliation(s)
- Kristi J Smock
- Department of Pathology, ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
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12
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Osti N, Beschin G, Goldin M, Guidolin L, Panero E, Sartori A, Parisi A, Cantini M, Pizzolo F, Olivieri O, Friso S. Case Report: Microangiopathic Hemolytic Anemia With Normal ADAMTS13 Activity. Front Med (Lausanne) 2021; 8:589423. [PMID: 33738292 PMCID: PMC7960662 DOI: 10.3389/fmed.2021.589423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/06/2021] [Indexed: 11/29/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) include a heterogeneous group of diseases characterized by abnormalities in the vessel walls of arterioles and capillaries resulting in microvascular thrombosis that typically presents with a microangiopathic hemolytic anemia (MAHA) and severe thrombocytopenia. We describe here the case of an 82-year-old woman, who came to our attention for a clinical condition consistent with thrombotic microangiopathy. Even if initially highly suggestive for a thrombotic thrombocytopenic purpura (TTP), the elevated ADAMTS13 activity together with the alteration of the main coagulation parameters (D-dimer elevation, fibrinogen consumption, slightly prolonged prothrombin time), induced us to consider several other diseases in the differential diagnostic process. The case evolved toward a suspected overlapped secondary hemophagocytic syndrome, though the hyperferritinemia was finally interpreted within the frame of a cytokine storm. After a complex diagnostic workup, the clinical and biochemical parameters guided us toward the diagnosis of a cancer-related microangiopathic hemolytic anemia (CR-MAHA) secondary to a relapsing breast cancer with multiple metastatic localizations. Prednisone 1 mg/kg body weight was started, and several units of fresh frozen plasma were infused, obtaining a good control of the hemolysis. No specific oncological therapies were, however, possible, due to the older age and the critically compromised general condition of the patient; therefore, after clinical stabilization, the patient was discharged for treatment in a palliative care Hospital.
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Affiliation(s)
- Nicola Osti
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Greta Beschin
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Marzia Goldin
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Lucia Guidolin
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Enrico Panero
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Alice Sartori
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Alice Parisi
- Department of Diagnostics and Public Health, School of Medicine, University of Verona, Verona, Italy
| | - Maurizio Cantini
- Department of Transfusion Medicine, University Hospital, Verona, Italy
| | - Francesca Pizzolo
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Oliviero Olivieri
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | - Simonetta Friso
- Department of Medicine, School of Medicine, University of Verona, Verona, Italy
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13
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Arays R, Shmookler AD. Educational Case: Warm Autoimmune Hemolytic Anemia. Acad Pathol 2020; 7:2374289520968228. [PMID: 33225062 PMCID: PMC7656867 DOI: 10.1177/2374289520968228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 08/27/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Ruta Arays
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Aaron D Shmookler
- Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University, Morgantown, WV, USA
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14
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Bray MA, Sartain SE, Gollamudi J, Rumbaut RE. Microvascular thrombosis: experimental and clinical implications. Transl Res 2020; 225:105-130. [PMID: 32454092 PMCID: PMC7245314 DOI: 10.1016/j.trsl.2020.05.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 02/07/2023]
Abstract
A significant amount of clinical and research interest in thrombosis is focused on large vessels (eg, stroke, myocardial infarction, deep venous thrombosis, etc.); however, thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Further, microvascular thrombosis has recently been demonstrated in patients with COVID-19, and has been proposed to mediate the pathogenesis of organ injury in this disease. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation. In this review, we discuss endogenous regulatory mechanisms that prevent thrombosis in the microcirculation, experimental approaches to induce microvascular thrombi, and clinical conditions associated with microvascular thrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation is anticipated to provide optimal therapeutic targets for patients with diseases accompanied by microvascular thrombosis.
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Key Words
- adamts13, a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13
- ap, alternate pathway
- apc, activated protein c
- aps, antiphospholipid syndrome
- caps, catastrophic aps
- asfa, american society for apheresis
- atp, adenosine triphosphate
- cfh, complement factor h
- con a, concavalin a
- cox, cyclooxygenase
- damp, damage-associated molecular pattern
- dic, disseminated intravascular coagulation
- gbm, glomerular basement membrane
- hellp, hemolysis, elevated liver enzymes, low platelets
- hitt, heparin-induced thrombocytopenia and thrombosis
- hlh, hemophagocytic lymphohistiocytosis
- hus, hemolytic-uremic syndrome
- isth, international society for thrombosis and haemostasis
- ivig, intravenous immunoglobulin
- ldh, lactate nos, nitric oxide synthase
- net, neutrophil extracellular trap
- pai-1, plasminogen activator inhibitor 1
- pf4, platelet factor 4
- prr, pattern recognition receptor
- rbc, red blood cell
- scd, sickle cell disease
- sle, systemic lupus erythematosus
- tlr, toll-like receptor
- tf, tissue factor
- tfpi, tissue factor pathway inhibitor
- tma, thrombotic microangiopathy
- tnf-α, tumor necrosis factor-α
- tpe, therapeutic plasma exchange
- ulc, ultra large heparin-pf4 complexes
- ulvwf, ultra-large von willebrand factor
- vwf, von willebrand factor
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Affiliation(s)
- Monica A Bray
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Sarah E Sartain
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Jahnavi Gollamudi
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Rolando E Rumbaut
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas.
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15
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Bahr TM, Judkins AJ, Christensen RD, Baer VL, Henry E, Minton SD, Gerday E, Bennett ST. Neonates with suspected microangiopathic disorders: performance of standard manual schistocyte enumeration vs. the automated fragmented red cell count. J Perinatol 2019; 39:1555-1561. [PMID: 31462723 DOI: 10.1038/s41372-019-0482-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To enhance the diagnosis of schistocyte-producing conditions, we compared routine manual schistocyte enumeration with automated fragmented red cell counts (FRCs). STUDY DESIGN In neonates "suspected" of having sepsis, NEC, or DIC we compared manual schistocyte estimates vs. automated FRC counts. When the two disagreed, we used a "gold standard" from a ≥ 1000 RBC differential. We also assessed the diagnostic accuracy of the FRC count in diagnosing sepsis, NEC, or DIC. RESULTS We collected 270 CBCs from 90 neonates. The methods agreed in 63% (95% CI 55%-70%) of the CBCs. Among the 37% where they disagreed, the FRC count was more accurate in 100% (95% CI 88-100%). An elevated FRC count was specific for sepsis, and was sensitive and specific for necrotizing enterocolitis and DIC. CONCLUSIONS Automated FRC counts have advantages over routine manual evaluation, larger sample size, lower expense, and superior accuracy in diagnosing schistocyte-producing conditions.
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Affiliation(s)
- Timothy M Bahr
- Department of Pediatrics, Division of Neonatology, University of Utah Health, Salt Lake City, UT, USA.
| | - Allison J Judkins
- Department of Pediatrics, Division of Neonatology, University of Utah Health, Salt Lake City, UT, USA
| | - Robert D Christensen
- Department of Pediatrics, Division of Neonatology, University of Utah Health, Salt Lake City, UT, USA.,Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Pediatrics, Division of Hematology/Oncology, University of Utah Health, Salt Lake City, UT, USA
| | - Vickie L Baer
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Erick Henry
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Stephen D Minton
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Pediatrics, Division of Neonatology, Utah Valley Hospital, Provo, UT, USA
| | - Erick Gerday
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Pediatrics, Division of Neonatology, Utah Valley Hospital, Provo, UT, USA
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16
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Li XY, Mai YF, Huang J, Pai P. Gastrointestinal infection-related disseminated intravascular coagulation mimicking Shiga toxin-mediated hemolytic uremic syndrome - implications of classical clinical indexes in making the diagnosis: A case report and literature review. World J Clin Cases 2019; 7:1660-1670. [PMID: 31367625 PMCID: PMC6658372 DOI: 10.12998/wjcc.v7.i13.1660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thrombocytopenia associated with acute kidney injury is a challenging disorder. Thrombotic microangiopathy (TMA) is a potentially life- or organ-threatening syndrome that can be induced by several disorders or medical interventions. There is overlap between the clinical presentation and pathophysiology of thrombotic thrombocytopenia purpura and hemolytic uremic syndrome (HUS), and to a lesser extent, disseminated intravascular coagulation (DIC). We describe a case to illustrate the potential diagnostic difficulty, especially at initial presentation.
CASE SUMMARY We reported a case of a 44-year-old woman that presented with diarrhea, thrombocytopenia, schistocytes, elevated serum lactate dehydrogenase (LDH) level and acute kidney injury. While the clinical presentation resembled that of Shiga toxin–induced HUS, the disease course was more consistent with gastrointestinal infection-related DIC. To aid in the accurate diagnosis of TMA and other associated disorders, we have undertaken a review and provided a clear interpretation of some typical biomarkers including schistocytes, LDH and platelet count, coagulation profile and more specific indexes of ADAMTS13, complement profile, and the isolation of Shiga toxin-producing Escherichia coli (commonly referred to as STEC).
CONCLUSION The use and correct interpretation of classical indexes of schistocyte, LDH, and platelet count is vital in diagnosing TMA and associated disorders. Understanding the characteristics of these biomarkers in the context of thrombocytopenia purpura, HUS and DIC will facilitate the accurate diagnosis and early initiation of appropriate treatment.
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Affiliation(s)
- Xiang-Yang Li
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Yan-Fen Mai
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Jing Huang
- Department of Hematology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Pearl Pai
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
- Department of Medicine, The University of Hong Kong - Queen Mary Hospital, Hong Kong, China
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17
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Ko DR, Kong T, Lee HS, Kim S, Lee JW, Chung HS, Chung SP, You JS, Park JW. Usefulness of the Thrombotic Microangiopathy Score as a Promising Prognostic Marker of Septic Shock for Patients in the Emergency Department. J Clin Med 2019; 8:jcm8060808. [PMID: 31174267 PMCID: PMC6617054 DOI: 10.3390/jcm8060808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 01/20/2023] Open
Abstract
The thrombotic microangiopathy (TMA) score based on the development and morphological characteristics of schistocytes is a rapid, simple biomarker that is easily obtained from the complete blood cell count by an automated blood cell analyzer. We aimed to determine whether the TMA score is associated with 30-day mortality of patients with early-stage septic shock. This observational cohort study was retrospectively conducted based on a prospective emergency department (ED) registry (June 2015–December 2016). We analyzed the TMA score at ED admission and 24 h later. The primary endpoint was all-cause mortality within 30 days of ED admission. A total of 221 patients were included. Increased TMA scores at time 0 (odds ratio (OR), 1.972; 95% confidence interval (CI), 1.253–3.106; p = 0.003) and at time 24 (OR, 1.863; 95% CI, 1.863–3.066; p = 0.014) were strong predictors of 30-day mortality. Increased predictability of 30-day mortality was closely associated with TMA scores ≥2 at time 0 (OR, 4.035; 95% CI, 1.651–9.863; p = 0.002) and ≥3 at time 24 (OR, 5.639; 95% CI, 2.190–14.519; p < 0.001). Increased TMA scores significantly predicted 30-day mortality for patients with severe sepsis and septic shock and can be helpful when determining the initial treatment strategies without additional costs or effort.
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Affiliation(s)
- Dong Ryul Ko
- Department of Emergency Medicine, Yonsei University College of Medicine, 06273 Seoul, Korea.
- Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, 24289 Chuncheon, Korea.
| | - Taeyoung Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, 06273 Seoul, Korea.
- Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, 24289 Chuncheon, Korea.
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 06273 Seoul, Korea.
| | - Sinae Kim
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 06273 Seoul, Korea.
| | - Jong Wook Lee
- Department of Laboratory Medicine, Konyang University Hospital, 35365 Daejon, Korea.
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 06273 Seoul, Korea.
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 06273 Seoul, Korea.
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, 06273 Seoul, Korea.
| | - Jong Woo Park
- Department of Emergency Medicine, Good Sunlin Hospital, 37725 Pohang, Korea.
- Department of Emergency Medicine, Graduate School of medicine, Kosin University, 49267 Busan, Korea.
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18
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Johnsen N, Hamilton ADM, Greve AS, Christensen MG, Therkildsen JR, Wehmöller J, Skals M, Praetorius HA. α-Haemolysin production, as a single factor, causes fulminant sepsis in a model of Escherichia coli-induced bacteraemia. Cell Microbiol 2019; 21:e13017. [PMID: 30761726 DOI: 10.1111/cmi.13017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 12/14/2022]
Abstract
α-Haemolysin (HlyA) from uropathogenic Escherichia coli has been demonstrated to be a significant virulence factor for ascending urinary tract infections. Once the E. coli reach the well-vascularised kidneys, there is a high risk of bacteraemia and a subsequent septic host response. Despite this, HlyA has the potential to accelerate the host response both directly and via its ability to facilitate adenosine triphosphate release from cells. It has not been settled whether HlyA aggravates bacteraemia into a septic state. To address this, we used an E. coli strain in a model of acute urosepsis that was either transfected with a plasmid containing the full HlyA operon or one with deletion in the HlyA gene. Here, we show that HlyA accelerates the host response to E. coli in the circulation. Mice exposed to HlyA-producing E. coli showed massively increased proinflammatory cytokines, a substantial fall in circulating thrombocytes, extensive haematuria, and intravascular haemolysis. This was not seen in mice exposed to either E. coli that do not secrete HlyA or vehicle controls. Consistent with the massive host response to the bacteria, the mice exposed to HlyA-producing E. coli died exceedingly early, whereas mice exposed to E. coli without HlyA production and vehicle controls survived the entire observation period. These data allow us to conclude that HlyA is a virulence factor that accelerates a state of bacteraemia into fulminant sepsis in a mouse model.
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Affiliation(s)
- Nanna Johnsen
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark
| | | | | | | | | | - Julia Wehmöller
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark
| | - Marianne Skals
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark
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19
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Harada Y, Komori I, Morinaga K, Shimizu T. Microangiopathic haemolytic anaemia with thrombocytopenia induced by vitamin B12 deficiency long term after gastrectomy. BMJ Case Rep 2018; 2018:bcr-2018-225915. [PMID: 30232206 DOI: 10.1136/bcr-2018-225915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Microangiopathic haemolytic anaemia with thrombocytopenia, called pseudo-thrombotic microangiopathy (TMA), is a clinically important complication in patients with vitamin B12 deficiency. We herein present a case of an 80-year-old woman with pseudo-TMA after gastrectomy. She was initially suspected with thrombotic thrombocytopenic purpura based on rapid progression of anaemia with schistocytes and thrombocytopenia; however, her anaemia and thrombocytopenia were improved by vitamin B12 supplementation alone, with a single session of plasma exchange. Vitamin B12 deficiency was finally confirmed by low vitamin B12 levels from the patient's initial blood sample. In addition, normal ADAMTS13 activity was proven, lowering the likelihood of thrombotic thrombocytopenic purpura. Therefore, this patient was diagnosed with pseudo-TMA caused by vitamin B12 deficiency. Pseudo-TMA can occur in patients with vitamin B12 deficiency post-gastrectomy.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Itsumi Komori
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Kouhei Morinaga
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
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20
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Yoon JG, Heo J, Kim M, Park YJ, Choi MH, Song J, Wyi K, Kim H, Duchenne O, Eom S, Tsoy Y. Machine learning-based diagnosis for disseminated intravascular coagulation (DIC): Development, external validation, and comparison to scoring systems. PLoS One 2018; 13:e0195861. [PMID: 29718941 PMCID: PMC5931474 DOI: 10.1371/journal.pone.0195861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/31/2018] [Indexed: 12/28/2022] Open
Abstract
The major challenge in the diagnosis of disseminated intravascular coagulation (DIC) comes from the lack of specific biomarkers, leading to developing composite scoring systems. DIC scores are simple and rapidly applicable. However, optimal fibrin-related markers and their cut-off values remain to be defined, requiring optimization for use. The aim of this study is to optimize the use of DIC-related parameters through machine learning (ML)-approach. Further, we evaluated whether this approach could provide a diagnostic value in DIC diagnosis. For this, 46 DIC-related parameters were investigated for both clinical findings and laboratory results. We retrospectively reviewed 656 DIC-suspected cases at an initial order for full DIC profile and labeled their evaluation results (Set 1; DIC, n = 228; non-DIC, n = 428). Several ML algorithms were tested, and an artificial neural network (ANN) model was established via independent training and testing using 32 selected parameters. This model was externally validated from a different hospital with 217 DIC-suspected cases (Set 2; DIC, n = 80; non-DIC, n = 137). The ANN model represented higher AUC values than the three scoring systems in both set 1 (ANN 0.981; ISTH 0.945; JMHW 0.943; and JAAM 0.928) and set 2 (AUC ANN 0.968; ISTH 0.946). Additionally, the relative importance of the 32 parameters was evaluated. Most parameters had contextual importance, however, their importance in ML-approach was different from the traditional scoring system. Our study demonstrates that ML could optimize the use of clinical parameters with robustness for DIC diagnosis. We believe that this approach could play a supportive role in physicians' medical decision by integrated into electrical health record system. Further prospective validation is required to assess the clinical consequence of ML-approach and their clinical benefit.
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Affiliation(s)
- Jihoon G. Yoon
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | | | - Yu Jin Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Hyuk Choi
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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21
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Delabranche X, Helms J, Meziani F. Immunohaemostasis: a new view on haemostasis during sepsis. Ann Intensive Care 2017; 7:117. [PMID: 29197958 PMCID: PMC5712298 DOI: 10.1186/s13613-017-0339-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
Host infection by a micro-organism triggers systemic inflammation, innate immunity and complement pathways, but also haemostasis activation. The role of thrombin and fibrin generation in host defence is now recognised, and thrombin has become a partner for survival, while it was seen only as one of the "principal suspects" of multiple organ failure and death during septic shock. This review is first focused on pathophysiology. The role of contact activation system, polyphosphates and neutrophil extracellular traps has emerged, offering new potential therapeutic targets. Interestingly, newly recognised host defence peptides (HDPs), derived from thrombin and other "coagulation" factors, are potent inhibitors of bacterial growth. Inhibition of thrombin generation could promote bacterial growth, while HDPs could become novel therapeutic agents against pathogens when resistance to conventional therapies grows. In a second part, we focused on sepsis-induced coagulopathy diagnostic challenge and stratification from "adaptive" haemostasis to "noxious" disseminated intravascular coagulation (DIC) either thrombotic or haemorrhagic. Besides usual coagulation tests, we discussed cellular haemostasis assessment including neutrophil, platelet and endothelial cell activation. Then, we examined therapeutic opportunities to prevent or to reduce "excess" thrombin generation, while preserving "adaptive" haemostasis. The fail of international randomised trials involving anticoagulants during septic shock may modify the hypothesis considering the end of haemostasis as a target to improve survival. On the one hand, patients at low risk of mortality may not be treated to preserve "immunothrombosis" as a defence when, on the other hand, patients at high risk with patent excess thrombin and fibrin generation could benefit from available (antithrombin, soluble thrombomodulin) or ongoing (FXI and FXII inhibitors) therapies. We propose to better assess coagulation response during infection by an improved knowledge of pathophysiology and systematic testing including determination of DIC scores. This is one of the clues to allocate the right treatment for the right patient at the right moment.
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Affiliation(s)
- Xavier Delabranche
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM, EFS Grand Est, BPPS UMR-S 949, Université de Strasbourg, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
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22
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Changes in novel haematological parameters following thermal injury: A prospective observational cohort study. Sci Rep 2017; 7:3211. [PMID: 28607467 PMCID: PMC5468303 DOI: 10.1038/s41598-017-03222-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/24/2017] [Indexed: 12/15/2022] Open
Abstract
The mortality caused by sepsis is high following thermal injury. Diagnosis is difficult due to the ongoing systemic inflammatory response. Previous studies suggest that cellular parameters may show promise as diagnostic markers of sepsis. The aim of this study was to evaluate the effect of thermal injury on novel haematological parameters and to study their association with clinical outcomes. Haematological analysis was performed using a Sysmex XN-1000 analyser on blood samples acquired on the day of the thermal injury to 12 months post-injury in 39 patients (15–95% TBSA). Platelet counts had a nadir at day 3 followed by a rebound thrombocytosis at day 21, with nadir values significantly lower in septic patients. Measurements of extended neutrophil parameters (NEUT-Y and NEUT-RI) demonstrated that septic patients had significantly higher levels of neutrophil nucleic acid content. A combination of platelet impedance count (PLT-I) and NEUT-Y at day 3 post-injury exhibited good discriminatory power for the identifying septic patients (AUROC = 0.915, 95% CI [0.827, 1.000]). Importantly, the model had improved performance when adjusted for mortality with an AUROC of 0.974 (0.931, 1.000). A combination of PLT-I and NEUT-Y show potential for the early diagnosis of sepsis post-burn injury. Importantly, these tests can be performed rapidly and require a small volume of whole blood highlighting their potential utility in clinical practice.
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23
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Schapkaitz E, Mezgebe MH. The Clinical Significance of Schistocytes: A Prospective Evaluation of the International Council for Standardization in Hematology Schistocyte Guidelines. Turk J Haematol 2016; 34:59-63. [PMID: 27795225 PMCID: PMC5451690 DOI: 10.4274/tjh.2016.0359] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: The presence of ≥1% schistocytes on a peripheral blood smear (PBS) is an important criterion for the diagnosis of thrombotic microangiopathy (TMA). The reporting of schistocytes has been standardized by the International Council for Standardization in Hematology (ICSH). Despite the availability of guidelines, however, the assessment of schistocytes remains subjective. More recently, the automated fragmented red cell (FRC) parameter has been evaluated. However, local studies are not available. Materials and Methods: A prospective study was performed at the Charlotte Maxeke Johannesburg Academic Hospital in order to evaluate the ICSH recommendations for schistocyte measurement in 146 PBSs with schistocytes. Schistocytes were evaluated by microscopy and ADVIA 2120 automated hematology analyzers. Results: Schistocytes were frequently observed in patients with TMA (n=76), infection (n=20), hematologic malignancy (n=10), renal failure (n=5), and hemoglobinopathy (n=15), and in neonates (n=11). Schistocytes were ≥1% in all PBSs with TMA (n=76) with a mean of 3.44±1.84. Schistocytes of ≥1% were also observed in cases of renal failure and hemoglobinopathy, and in neonates. In these conditions, schistocytes were mainly observed in conjunction with moderate red blood cell changes. The agreement between two morphologists gave a correlation coefficient of 0.63 [confidence interval (CI): 0.52-0.75], while the correlation coefficient between the average of the morphologists and the FRC percentage was -1.97 (CI: -1.60 to -2.34). The ADVIA 2120 underestimated the schistocyte count in patients with TMA. Conclusion: Observer bias can be decreased by implementing the standardized procedures recommended by the ICSH. However, estimation of schistocytes by the ADVIA 2120 analyzer requires further evaluation as a screening tool. A higher threshold for schistocytes in thrombotic thrombocytopenic purpura is recommended to distinguish this hematological emergency from other conditions associated with ≥1% schistocytes.
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Affiliation(s)
- Elise Schapkaitz
- University of Witwatersrand Medical School, Department of Molecular Medicine and Hematology, Johannesburg, South Africa Phone: +27824592238 E-mail:
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24
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Guthoff M, Heyne N. [Clinical course and differential diagnosis of thrombotic microangiopathy]. Med Klin Intensivmed Notfmed 2016; 113:293-298. [PMID: 27405938 DOI: 10.1007/s00063-016-0193-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thrombotic microangiopathies are complex diseases, requiring early differential diagnosis and targeted intervention. OBJECTIVES Presentation of clinical phenotype and diagnostic algorithm, discussion of underlying pathophysiology, clinical management and therapy. METHODS Summary of current knowledge from literature and expert opinion. RESULTS Our understanding of pathophysiology and therapeutic options have changed substantially in recent years. Early differential diagnosis and targeted therapy are of prognostic relevance. CONCLUSIONS A better understanding of underlying pathophysiology, increased clinical awareness and novel therapeutic options allow for a better prognosis of patients with thrombotic microangiopathy.
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Affiliation(s)
- M Guthoff
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
| | - N Heyne
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
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25
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Hervent AS, Godefroid M, Cauwelier B, Billiet J, Emmerechts J. Evaluation of schistocyte analysis by a novel automated digital cell morphology application. Int J Lab Hematol 2015; 37:588-96. [DOI: 10.1111/ijlh.12363] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 02/17/2015] [Indexed: 12/14/2022]
Affiliation(s)
- A.-S. Hervent
- Department of Laboratory Hematology; AZ Sint-Jan; Bruges Belgium
| | - M. Godefroid
- Department of Laboratory Hematology; AZ Sint-Jan; Bruges Belgium
| | - B. Cauwelier
- Department of Laboratory Hematology; AZ Sint-Jan; Bruges Belgium
| | - J. Billiet
- Department of Laboratory Hematology; AZ Sint-Jan; Bruges Belgium
| | - J. Emmerechts
- Department of Laboratory Hematology; AZ Sint-Jan; Bruges Belgium
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26
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Hager HB, Nyquist E, Jacobsen RA, Hager AM. En kvinne i 60-årene med store trombemasser i aorta. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:1853-7. [DOI: 10.4045/tidsskr.15.0311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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