A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study

Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment. We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1-75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.

Prognostic significance of antithrombin activity in patients with crimean-congo hemorrhagic Fever

OBJECTIVE

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral hemorrhagic fever. Disseminated intravascular coagulation (DIC) is an important complication of this disease, especially in severe and fatal cases. Antithrombin (AT) acts as an anticoagulant by inactivating thrombin, Factor IX, Factor X and Factor XI. We conducted this study to investigate the AT levels and their prognostic value in CCHF.

MATERIALS AND METHODS

Twenty-eight confirmed CCHF patients were included in this study. Diagnosis of the disease was made by CCHF IgM and/or PCR positivity. Patients were grouped based on the severity criteria described previously. The patients with platelet counts <20 000×10(6) cell/L, white blood counts >10×10(9) cell/L, prothrombin times >60 seconds, aspartate aminotransferase levels >700 IU/L or alanine aminotransferase levels >900 IU/L were accepted as severe cases. Patients whose illnesses were self-limited and who did not require blood component replacement were accepted as mild cases, and patients who improved but required blood component replacement were accepted as moderate cases. Blood samples were obtained on the day that the patient had the lowest platelet count and before any thrombocyte replacement. The antithrombin activity was measured using a chromogenic substrate test (Diagnostica Stago STA Compact) at a research laboratory.

RESULTS

Twenty-two (78.6%) of the cases were mild, 3 (10.7%) were moderate, and 3 were (10.7%) severe. The mean AT value was 101% for mild cases, 116.6 % for moderate cases, and 88% for severe cases (p>0.05). Although there were no statistically significant differences between the AT values, the mean AT activity was lower in severe CCHF cases.

CONCLUSION

The AT activity may have been decreased in severe CCHF cases. Further studies with greater numbers of patients are required to determine the level of AT activity and its correlation with disease severity and the prognosis of CCHF.

Therapeutic plasma exchange in patients with neurological diseases: multicenter retrospective analysis

Therapeutic plasma exchange (TPE), is a procedure, changing pathologic substances in the plasma of patients with replacement fluid. TPE has an increasing list of indications in recent years such as neurological, connective tissue, hematological, nephrological, endocrinological and metabolic disorders. We report our multicenter data about therapeutic plasma exchange in patients with neurological diseases. Six University Hospitals' aphaeresis units medical records about neurologic diseases were reviewed retrospectively. Hundred and fifteen patients and 771 TPE sessions from six aphaeresis units' were included to this study. Of the 115 patients, 53 (46%) were men and 62 (54%) were women. The median age was 50 (range: 5-85) years. Of these patients 58.3% were Guillain-Barre syndrome (GBS), 17.4% were acute disseminated encephalomyelitis (ADEM), 10.4% were chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), 7% were multiple sclerosis, 6.1% were myasthenia gravis (MG) and 0.9% were Wilson disease (WD). The median number of TPE sessions per patient was 5 (range 1-72). Human albumin was used as a replacement fluid in 66% and fresh frozen plasma was used in 34% of cases. TPE was done through central venous catheters in 66%, and peripheral venous access in 34% of patients. Some complications were seen in patients (18.3%) during TPE sessions. These complications were, complications related to catheter placement procedure (8.7%), hypotension (3.5%), hypocalcaemia (3.5%) and allergic reactions (1.7%). The complication ratios were 2.7% in total 771 TPE procedures. TPE procedure was terminated in 6% of sessions depending on these complications. Overall responses to TPE were noted in 89.5% of patients. In conclusion; Therapeutic plasma exchange is an effective treatment option in several neurologic diseases.

Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura: a retrospective multicenter study

Thrombotic thrombocytopenic purpura (TTP) is a particular form of thrombotic microangiopathy typically characterized by thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological abnormalities, and renal dysfunction. TTP requires a rapid diagnosis and an adapted management in emergency. Daily sessions of therapeutic plasma exchange (TPE) remain the basis of management of TTP. Also, TTP is a rare disease that is fatal if it is not treated. TPE has resulted in excellent remission and survival rates in TTP patients.

AIM

We aimed to present our experience in 163 patients with TTP treated with TPE during the past 5years from 10 centers of Turkey.

PATIENTS AND METHODS

One hundered and sixty-three patients with TTP treated with TPE during the past 5years from 10 centers of Turkey were retrospectively evaluated. TPE was carried out 1-1.5times plasma volume. Fresh frozen plasma (FFP) was used as the replacement fluid. TPE was performed daily until normalization of serum lactate dehydrogenase (LDH) and recovery of the platelet count to >150×10(9)/dL. TPE was then slowly tapered. Clinical data, the number of TPE, other given therapy modalities, treatment outcomes, and TPE complications were recorded.

RESULTS

Fifty-eight percent (95/163) of the patients were females. The median age of the patients was 42years (range; 16-82). The median age of male patients was significantly higher than female (53 vs. 34years; p<0.001). All patients had thrombocytopenia and microangiopathic hemolytic anemia. At the same time, 82.8% (135/163) of patients had neurological abnormalities, 78.5% (128/163) of patients had renal dysfunction, and 89% (145/163) of patients had fever. Also, 10.4% (17/163) of patients had three of the five criteria, 10.4% (17/163) of patients had four of the five criteria, and 6.1% (10/163) of patients had all of the five criteria. Primary TTP comprised of 85.9% (140/163) of the patients and secondary TTP comprised of 14.1% (23/163) of the patients. Malignancy was the most common cause in secondary TTP. The median number of TPE was 13 (range; 1-80). The number of TPE was significantly higher in complete response (CR) patients (median 15.0 vs. 3.5; p<0.001). CR was achieved in 85.3% (139/163) of the patients. Similar results were achieved with TPE in both primary and secondary TTP (85% vs. 87%, respectively; p=0.806). There was no advantage of TPE+prednisolone compared to TPE alone in terms of CR rates (82.1% vs. 76.7%; p=0.746). CR was not achieved in 14.7% (24/163) of the patients and these patients died of TTP related causes. There were no statistical differences in terms of mortality rate between patients with secondary and primary TTP [15% (21/140) vs. 13% (3/23); p=0.806]. But, we obtained significant statistical differences in terms of mortality rate between patients on TPE alone and TPE+prednisolone [14% (12/86) vs. 3% (2/67), p<0.001].

CONCLUSIONS

TPE is an effective treatment for TTP and is associated with high CR rate in both primary and secondary TTP. Thrombocytopenia together with microangiopathic hemolytic anemia is mandatory for the diagnosis of TTP and if these two criteria met in a patient, TPE should be performed immediately.

Relation of coronary collateral circulation with red cell distribution width in patients with non-ST elevation myocardial infarction

OBJECTIVES

We aimed to investigate the relationship between red cell distribution width (RDW) value and coronary collateral circulation (CCC) in patients with non-ST elevation myocardial infarction (NSTEMI).

METHODS

The study population consisted of 322 consecutive patients with NSTEMI. The patients were classified into impaired CCC (group 1, Rentrop grades 0-1) or good CCC (group 2, Rentrop grades 2-3). Baseline RDW was measured as part of the automated complete blood count.

RESULTS

The RDW values were significantly higher in patients with impaired CCC than in those with good CCC (17.2 ± 2.3 vs 14.5 ± 2.5, P < .001). In multivariate logistic regression analysis, RDW (odds ratio: 1.52, 95% confidence interval: 1.30-1.78, P < .001), baseline creatine kinase MB (CK-MB), and absence of preinfarction angina were found to be the independent predictors of impaired CCC. In receiver-operating characteristic curve analysis, the RDW value >15.5 yielded an area under curve value of 0.783, with 77% sensitivity and 73% specificity.

CONCLUSIONS

Our study results demonstrated that, high RDW, high CK-MB, and absence of preinfarction angina were found to be independent predictors of impaired CCC.

Comparative study of three angiotensin II type 1 receptor antagonists in preventing liver fibrosis in diabetic rats: stereology, histopathology, and electron microscopy

The presence of liver disease in patients with progressively worsening insulin resistance may not be recognized until patients develop manifestations of the metabolic syndrome such as diabetes, hypertension, hyperlipidemia, and vascular disease. It was aimed to investigate whether three angiotensin II type 1 receptor antagonists (ARBs) (olmesartan, losartan, and valsartan) had preventive effect against hepatic fibrosis and this was a common characteristic among ARBs. In current study, 25 adult male rats were used and divided into five groups: the non-diabetic healthy group, alloxan induced diabetic (AID) control group, AID losartan group, AID valsartan group and AID olmesartan group. According to numerical density of hepatocytes, significant difference was found between the non-diabetic healthy group and diabetic control group. All treatments groups were significant when compared to diabetic control group. In diabetic control group it was examined swelling, irregular cristae arrangement in some of mitochondria. It was also determined mitochondria membrane degeneration in some areas of section profiles. In diabetic rats treated with losartan group, there were necrotic hepatocytes. In diabetic rats treated with valsartan group, predominantly, findings were similar to losartan group. In diabetic rats treated with olmesertan group, plates of hepatocytes were quite regular. There were hardly necrotic cells. Not only other organelles such as RER, SER and lysosom but also mitochondrial structures had normal appearance. In the diabetic control group electron microscopy revealed edema in both the cytoplasm and perinuclear area and the nuclear membranes appeared damaged. In conclusion, it was established that the most protective ARB the liver in diabetic rats was olmesartan, followed by losartan.

Acute promyelocytic leukemia, centre, experience, Turkey

Acute promyelocytic leukemia (APL) is a specific type of acute myeloid leukemia (AML) and has distinct hematopathologic, cytogenetic, clinical and molecular features. This study was a retrospective review of 18 adult patients (10 male, 8 female; mean age of 32.17 ± 5.66 (15-61 years) with APL at our department from January 2006 to December 2011. Following induction therapy, 17 patients achieved CR, 1 of 18 patients died of result bleeding within thirty-sixth hours of admission. In two of 18 patients developed RAS. The relapse rate was 27% (5/18). Fourteen of 18 patients (77%) have been followed in remission. APL is a malignancy requiring quick diagnosis, efficient treatment and supportive care system. ATO, one of the important therapy option in the treatment of APL, cannot be obtained easily in developing countries. This may lead to an increase in the mortality rates. The studies should be made with more number of patients and a longer period of time for accurate results.

A simple, safe and effective approach to prevent postdural puncture headache: epidural saline injection

OBJECTIVE

In this study, we investigated the safety and effectiveness of epidural saline injection to prevent post-dural puncture headache (PDPH) in patients with acute lymphoblastic leukemia (ALL).

MATERIALS AND METHODS

Thirty-three patients with ALL undergoing induction therapy were accepted for the study. Four to six courses of intrathecal methotrexate therapy were administered to each patient for central nervous system prophylaxis. Patients were divided into two groups. Lumbar puncture (LP) was performed without any additional intervention in the first group (18 cases), whereas 20 mL of isotonic saline was injected into the epidural space in the second group (15 cases). The frequency and severity of PDPH were compared between the two groups.

RESULTS

Thirteen patients from the first group and five patients from the second group experienced at least one PDPH episode. In total, 54 PDPH episodes were reported in both groups. The rate of headache due to the LP was significantly higher in the first group than in the second group (48.8% vs. 16.4%, p<0.001). On the other hand, the severity of pain was also significantly higher in the first group (mean pain scores were 5.6 ± 1.62 vs. 3.07 ± 1.18, p<0.001). Furthermore, two patients from the first group (11.11%) developed generalized convulsion attacks, and one of those patients experienced pulmonary arrest necessitating respiratory support. No serious complications were observed in the second group.

CONCLUSIONS

Our study shows that isotonic saline injection into the epidural space after LP is a safe and effective approach to prevent PDPH and related complications.

[Seroprevalence of parvovirus B19 in patients with chronic idiopathic thrombocytopenic purpura]

Although there are several studies indicating the relationship between parvovirus B19 (PV-B19) and acute idiopathic thrombocytopenic purpura (ITP) which is a form seen frequently in children, the data are not enough in terms of chronic ITP, which is a more insidious form frequently seen in adults. The aim of this study was to investigate PV-B19 seroprevalence in adult chronic ITP cases diagnosed at the haematology clinics of Atatürk University Research Hospital in Erzurum (located in eastern Anatolia, Turkey). A total of 61 patients (38 female, 23 male; mean age: 34.4 +/- 11.2 years) and 60 healthy control subjects (30 female, 30 male; mean age: 35.6 +/- 9.6 years) were included to the study. All possible etiological agents and factors other than PV-B19 were eliminated on the basis of clinical and laboratory findings. PV-B19 antibodies were screened by ELISA method, and 73.7% (45/61) of the patients were found IgG, whereas 3.2% (2/61) were found IgM seropositive. In the control group, these rates were detected as 38.3% (23/60) and 1.6% (1/60), respectively. IgG antibodies were negative in the two patients and one control who were positive for IgM. The presence of PV-B19 DNA was investigated in all of the three IgM positive subjects, and was found positive in only one patient by real-time polymerase chain reaction (PCR). The difference between patient and control groups with regard to IgG seropositivity was found statistically significant (p < 0.01), however statistical evaluation could not be performed for IgM seropositivity because of the low number of cases. As a result although the rate of IgG positivity was found statistically higher in the ITP patients in our study, this data is inefficient for the evaluation of relationship between PV-B19 and chronic ITP, indicating the need for further studies.

Thrombotic thrombocytopenic purpura in a patient with Brucella infection is highly responsive to combined plasma infusion and antimicrobial therapy

OBJECTIVE

To report a case of brucella infection presenting with thrombotic thrombocytopenic purpura (TTP) that responded well to plasma and antimicrobial treatment infusion.

CASE PRESENTATION AND INTERVENTION

A 51-year-old man with moderate confusion, depressed mood and dysarthria was admitted. He was chronically ill, with fever (38.5 degrees C), anemia, jaundice and petechial-purpuric skin lesions. Neurological examination revealed diminished consciousness with a Glasgow coma scale score of 7 and +1 neck rigidity. The hemoglobin and platelet counts were decreased and reticulocyte index, erythrocyte sedimentation rate, as well as serum lactate dehydrogenase and renal dysfunction were elevated. TTP was a possible diagnosis and the patient responded well to plasma infusion and antimicrobial treatment.

CONCLUSION

This report shows that therapy of underlying infection together with plasma infusion may be a successful treatment option for brucellosis-induced TTP.

Tumour necrosis factor-alpha levels in hepatitis B virus-related chronic active hepatitis and liver cirrhosis and its relationship to Knodell and Child-Pugh scores

Although both chronic active hepatitis-B (CAH-B) and liver cirrhosis (LC) are characterised by various degrees of inflammation and hepatocyte necrosis, in advanced stage cirrhosis, marked fibrosis develops and inflammation and tissue necrosis diminishes. In this study, we aimed to investigate serum tumour necrosis factor-alpha (TNF-alpha) concentration in patients with CAH-B and LC and its relationship to disease activity. Serum samples were taken from 30 patients with CAH-B and 30 with LC at different stages of the disease. TNF-alpha concentrations were measured by the ELISA technique. Results were compared with those of 30 healthy controls. Mean plasma TNF-alpha levels were found as 2.47 +/- 2.98, 0.8 +/- 1.21 and 0.72 +/- 1.08 pg/ml in CAH-B, LC and control groups, respectively. TNF-alpha levels were significantly higher in CAH-B group than LC and control groups (p <0.01 and p < 0.05, respectively). Although mean plasma TNF-alpha level of cirrhotic patients at Child-A stage was markedly high (3.31 +/- 0.15), no significant difference has been found between LC and control groups (p > 0.05). TNF-alpha concentrations were positively correlated with hepatitis activity index (Knodell's score) in CAH-B group whereas negatively correlated with Child-Pugh score in LC group (r =0.73, p < 0.01 and r = -0.42, p < 0.05, respectively). Our study showed that TNF-alpha level increases in patients with CAH-B correlated with histologic activity index. So it can be used to evaluate disease activity. Additionally, marked reduction of TNF-alpha concentration in advanced cirrhosis suggested that TNF-alpha production is determined by hepatic damage and inflammation.

Crimean-Congo hemorrhagic fever in Eastern Turkey: clinical features, risk factors and efficacy of ribavirin therapy

OBJECTIVES

This study described the clinical features, factors affecting the outcome of this disease, risk factors, and efficacy of ribavirin therapy for CCHF patients in Eastern Turkey.

METHODS

Between 2002 and 2004, 60 cases admitted to our hospital were included in this study. The diagnosis was confirmed through detection of IgM by ELISA and/or genomic segment of virus by RT-PCR.

RESULTS

In multivariate analysis, farming (OR, 11.4), living in a rural area (OR, 10.05) and being bitten by tick (OR, 6.75) were determined as risk factors for CCHF. The rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites, and presence of petechia/ecchymosis were higher in the patients who died than in surviving ones. Additionally, the mean values of ALT, AST, LHD, CK, PTT, INR and urea were also higher, and the mean PLT count was lower in the patients who died. Mean recovery time was shorter in the cases treated with ribavirin than those of control. But, the need for blood and blood product, mean hospitalization duration, fatality rates, and hospital expenditure values were not significantly different between the group of patients treated with ribavirin and control groups.

CONCLUSIONS

In Eastern Turkey, clinical features, factors influencing outcome of the disease, and risk factors were similar to other outbreaks of CCHF. Further studies are needed for the evaluation of ribavirin therapy in CCHF.

Genotoxic effect of ribavirin in patients with Crimean-Congo hemorrhagic fever

In this study, we investigated the in vivo genotoxicity of ribavirin in humans, studying 3 patients with Crimean-Congo hemorrhagic fever who were treated with high-dose ribavirin. In order to evaluate genotoxicity, both the micronucleus (MN) test and the sister chromatid exchange (SCE) test were used. In all patients, blood samples were taken during and after therapy. Whole blood cultures were performed for 72 h and the MN assay and SCE test were then carried out to demonstrate the genotoxicity. In all patients, both SCE and MN amounts were found to be higher in the samples which were taken during therapy than in those at 1 month after therapy. The results of our study reveal that ribavirin has a reversible in vivo genotoxic effect on humans.

Morphological alterations produced by zinc deficiency in rat sciatic nerve: a histological, electron microscopic, and stereological study

Zinc (Zn) is an essential trace element for humans and animals. It is required for normal growth, gene expression, wound healing, protein metabolism, immune function, and membrane integrity. In this study, unbiased stereological methods have been used to quantify the effects of Zn deficiency on the sectioned surface area and the number of myelinated axons in the sciatic nerve of rats. Animals were fed a Zn-deficient or Zn-sufficient diet for a period of 4 weeks. At the end of this time, the samples of sciatic nerves were removed from the animals, processed for electron microscopy and embedded in resin. The Zn-deficient group of rats was found to have a lower body weight compared to rats in the control group (P < 0.05). The sectioned surface area of nerve cross-section and myelinated axon number in Zn-deficient rats decreased by 20% and 29%, respectively, compared to the control group. A significant correlation between sectioned surface area and myelinated axon number was also determined. Morphological findings were as follows: on light microscopy, it was determined that certain abnormalities occur specifically in the experimental group, such as collapsed nerve fascicles, irregular profiles of and degeneration in myelin sheaths, and on electron microscopy, extensive myelin damage was seen in Zn-deficient groups compared with control groups. This study suggests that peripheral nerves require Zn for development and preservation of their structure.

Vascular endothelial and basic fibroblast growth factor serum levels in patients with Behçet’s disease

Behçet's disease (BD) is a systemic vasculitis of unknown aetiology. Its pathogenesis is related to endothelial cell dysfunction, humoral immune defects, and immune system dysregulation. The aim of this study was to investigate the possible role of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in the pathogenesis of BD. We also investigated whether disease activity, age, or duration of BD correlates with VEGF and bFGF. We studied 33 patients and 20 healthy controls. Vascular endothelial growth factor and bFGF serum levels were measured by enzyme-linked immunosorbent assay. We measured acute phase reactants, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The mean serum VEGF level was significantly higher in patients with BD (398.8+/-222.2 pg/ml) than the control group (193.0+/-122.4 pg/ml) (P=0.002). The levels were similar in both active and inactive BD (P=0.675) but did not correlate with disease duration, CRP, ESR, or age (P>0.05 for each). The bFGF was below detection limits in 18 of 33 patients with BD and ten of 20 controls, and its mean serum level was higher in BD patients (42.4+/-76.9 pg/ml) than controls (29.0+/-9.1 pg/ml), but this difference was not statistically significant (P=0.232). The bFGF levels were similar in both active and inactive BD (P=0.09) and, in patients, correlated with disease duration and CRP (r=0.58, P=0.02; r=-0.57, P=0.02, respectively) but not with ESR or age (P>0.05 for each). Vascular endothelial growth factor may be more important in the pathogenesis of BD than bFGF. Neither growth factor is an activity criterion or inflammatory marker in BD.