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Khan U, Sharma S, Prasad P, Agarwal A, Jain A, Jain A, Verma H. Enhancing Plasmapheresis Efficacy in Waldenstrom Macroglobulinemia: Overcoming Circuit Clotting Challenges. Semin Dial 2024; 37:282-283. [PMID: 38506146 DOI: 10.1111/sdi.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/18/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Urvashi Khan
- Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sourabh Sharma
- Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Pallavi Prasad
- Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Anupam Agarwal
- Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ankur Jain
- Department of Haematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Aditi Jain
- Department of Haematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Himanshu Verma
- Department of Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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2
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Hussein EA. Factors affecting clinical outcomes of continuous and intermittent plasmapheresis in patients with severe hypertriglyceridemia. Ther Apher Dial 2024. [PMID: 38676441 DOI: 10.1111/1744-9987.14134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/08/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Acute hypertriglyceridemia is considered a category III indication for plasmapheresis. The use of plasma as replacement fluid (RF) has been suggested to replace the consumed lipoprotein lipase. Heparin when used as an anticoagulant could possibly release lipoprotein lipase, thereby increasing triglyceride clearance. METHODS The impact of RF (albumin vs fresh frozen plasma (FFP) and anticoagulant (ACD-A vs. heparin) on triglycerides following plasmapheresis in 27 patients with severe hypertriglyceridemia (SHTG) was investigated. A paired study of four patients with recurrent SHTG was conducted, evaluating continuous (Optia) versus intermittent flow plasmapheresis (Haemonetics). RESULTS Shorter procedures positively impacted triglycerides (TG) drop post-sessions p < 0.05. In albumin sessions, patients who used heparin demonstrated significantly greater drop in TG and required less sessions than did those with citrate p < 0.05. In heparin sessions, patients who used albumin demonstrated significantly greater drop in triglycerides and required less sessions than did those with FFP p < 0.05. Three of six patients who used FFP and heparin showed a triglyceride drop of 11.7% following three sessions and a 50% drop with one albumin session. Compared with Haemonetics, Optia removed comparable volumes of plasma in less time, processing smaller blood volumes and using less citrate p < 0.05. Patients demonstrated significantly lower drop in TG and required more sessions with Haemonetics than they did with Optia p < 0.05. CONCLUSION Shorter procedure was the main predictor for effective TG clearance. This can be achieved by continuous apheresis technology, particularly when using albumin as RF. TG removal via Optia seems to be optimized by using heparin.
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Affiliation(s)
- Eiman A Hussein
- Department of Clinical and Chemical Pathology, Division of Transfusion Medicine, Apheresis unit of Kasr Alainy Blood Bank, Faculty of Medicine, Cairo University, Cairo, Egypt
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3
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Saito S, Hontsu S, Hiraoka J, Yamanaka A, Fujioka N, Shimada D, Okuda Y, Sugie K, Muro S. A Rare Case of Overlapping Durvalumab-induced Myositis, Takotsubo-like Morphological Changes Caused by Myocarditis, and Myasthenia Gravis. Intern Med 2024:3028-23. [PMID: 38658343 DOI: 10.2169/internalmedicine.3028-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Immune checkpoint inhibitors can cause a range of immune-related adverse events, including myositis, Takotsubo cardiomyopathy, and myasthenia gravis. We herein report a rare case of a 78-year-old man with concurrent durvalumab-induced myositis, Takotsubo-like morphological changes caused by myocarditis, and myasthenia gravis. The patient initially required invasive ventilation and exhibited symptoms of myasthenia gravis after treatment with high-dose steroids. However, he subsequently achieved successful recovery after the administration of intravenous immunoglobulin, plasmapheresis, and high-dose steroids. We advocate vigilant neurological monitoring of patients with immune checkpoint inhibitor-induced myositis, including the assessment of ptosis and other relevant signs, so that prompt treatment can be initiated at the time of emergence or progression of immune checkpoint inhibitor-induced myasthenia gravis.
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Affiliation(s)
- Shoichiro Saito
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Shigeto Hontsu
- Department of Respiratory Medicine, Nara Medical University, Japan
| | - Junya Hiraoka
- Department of Respiratory Medicine, Nara Medical University, Japan
| | - Ai Yamanaka
- Department of Neurology, Nara Medical University, Japan
| | - Nobuhiro Fujioka
- Department of Respiratory Medicine, Nara Medical University, Japan
| | | | - Yosuke Okuda
- Department of Respiratory Medicine, Nara Medical University, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Japan
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Hughes W, Blair S, Rose H. To bite the hand that feeds you: A case of thrombotic microangiopathy due to Tiger snake bite. Nephrology (Carlton) 2024. [PMID: 38599614 DOI: 10.1111/nep.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/02/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
This report details the case of a 51-year-old man with a Tiger snake bite who developed systemic envenomation, coagulopathy and thrombotic microangiopathy (TMA) requiring renal replacement therapy. He received plasma exchange as additional therapy while awaiting confirmation of the cause of the TMA. We discuss clinical decision making in detection of systemic envenomation and management of the rare complication of TMA, as well as current Australian guidelines around antivenom administration. This is the fourth known documented case of TMA from a Tiger snake bite in Australia.
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Affiliation(s)
- William Hughes
- Department of General Medicine, Barwon Health University Hospital Geelong, Geelong, Victoria, Australia
| | - Susan Blair
- Department of Nephrology, Barwon Health University Hospital Geelong, Geelong, Victoria, Australia
| | - Hannah Rose
- Department of Haematology, Barwon Health University Hospital Geelong, Geelong, Victoria, Australia
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5
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Bonmatí-Santané A, Céspedes López R, Alvarez Saltos JJ, Calabia Martínez J, Noboa Paez C, Piedra Sánchez J, Visa Figueredo N, Maroto González A. Managing a Pregnancy in the Presence of the Rare Blood Group Antibody PP1Pk. Womens Health Rep (New Rochelle) 2024; 5:319-323. [PMID: 38596479 PMCID: PMC11002322 DOI: 10.1089/whr.2023.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 04/11/2024]
Abstract
Pregnant women with p phenotype, who lack antigens P, P1, and Pk, spontaneously form anti-PP1Pk antibodies whose primary target is the placenta. The risk of miscarriage in these women is 50%-70% and reaches 87% in the second trimester. The therapies aim to reduce the titer of antibodies early in pregnancy. They also have risk of hemolytic transfusion reaction, with very few compatible red blood cell donors in the world. In this study, we present a case of successful pregnancy managed with autologous blood donations and plasmapheresis.
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Affiliation(s)
| | | | | | | | - Cristina Noboa Paez
- Nephrorolgy Service; Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain
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Aljabri B, Saber W, Alzahrani S, Dada A. Resolution of Extensive Xanthomas Associated With Severe Hypertriglyceridemia via Modified Therapeutic Plasma Exchange. JCEM Case Rep 2024; 2:luae054. [PMID: 38601066 PMCID: PMC11005844 DOI: 10.1210/jcemcr/luae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Indexed: 04/12/2024]
Abstract
Severe hypertriglyceridemia can be manifested by xanthomas. Therapeutic plasma exchange (TPE) is an invasive medical procedure that has been documented as a viable approach for severe hypertriglyceridemia when cases would be refractory to conventional therapies. TPE is mainly an optional therapeutic modality for cases of severe acute pancreatitis or preventing the recurrence of pancreatitis. Beyond this clinical application, data are scarce on TPE utilization in managing cutaneous lesions associated with hypertriglyceridemia. We present a case of severe hypertriglyceridemia accompanied by extensive xanthomas of various types and a history of recurrent pancreatitis. After conventional therapy failed, a modified plasmapheresis regimen was used and was able to achieve a fast and marked reduction in the patient's serum triglyceride levels with complete resolution of the extensive cutaneous lesions, providing him a newfound comfort he had not experienced in some time and suggesting the regimen potentially could be considered in the treatment of refractory severe hypertriglyceridemia with debilitating cutaneous complications.
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Affiliation(s)
- Bandari Aljabri
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah 23431, Saudi Arabia
| | - Wafa Saber
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah 23431, Saudi Arabia
| | - Saud Alzahrani
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah 23431, Saudi Arabia
| | - Ashraf Dada
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Jeddah 23431, Saudi Arabia
- College of Medicine, Al Faisal University, Riyadh 11533, Saudi Arabia
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Abboud Y, Shah M, Simmons B, Mandava K, Morales JEM, Jaber F, Alsakarneh S, Ismail M, Hajifathalian K. Hypertriglyceridemia-induced acute necrotizing pancreatitis: Poor clinical outcomes requiring revisiting management modalities. JGH Open 2024; 8:e13061. [PMID: 38617108 PMCID: PMC11015164 DOI: 10.1002/jgh3.13061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 04/16/2024]
Abstract
Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is the third most common cause of AP after gallstones and alcohol. Supportive measures, intravenous insulin, and plasmapheresis are possible treatment modalities for HTG-AP; however, definitive guidelines evaluating the best therapeutic approach are not clearly established. We present a rare case of a 42-year-old male without known comorbidities who was found to have HTG-AP. Despite early initiation of intravenous insulin and plasmapheresis and the initial decline in his triglycerides level, his condition was complicated by necrotizing pancreatitis and subsequent multi-organ failure. Future studies are warranted to evaluate the role of plasmapheresis in HTG-AP and its efficacy.
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Affiliation(s)
- Yazan Abboud
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Meet Shah
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Benjamin Simmons
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Kranthi Mandava
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - John E M Morales
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Fouad Jaber
- Department of Internal MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Saqer Alsakarneh
- Department of Internal MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Mohamed Ismail
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Kaveh Hajifathalian
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
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8
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Potter RA, Peterson EL, Griffin D, Cooper Olson G, Lewis S, Cochran K, Mendell JR, Rodino-Klapac LR. Use of plasmapheresis to lower anti-AAV antibodies in nonhuman primates with pre-existing immunity to AAVrh74. Mol Ther Methods Clin Dev 2024; 32:101195. [PMID: 38327805 PMCID: PMC10847772 DOI: 10.1016/j.omtm.2024.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Abstract
Patients with pre-existing immunity to adeno-associated virus (AAV) are currently unable to receive systemic gene transfer therapies. In this nonhuman primate study, we investigated the impact of immunosuppression strategies on gene transfer therapy safety and efficacy and analyzed plasmapheresis as a potential pretreatment for circumvention of pre-existing immunity or redosing. In part 1, animals received delandistrogene moxeparvovec (SRP-9001), an AAVrh74-based gene transfer therapy for Duchenne muscular dystrophy. Cohort 1 (control, n = 2) received no immunosuppression; cohorts 2-4 (n = 3 per cohort) received prednisone at different time points; and cohort 5 (n = 3) received rituximab, sirolimus, and prednisone before and after dosing. In part 2, cohorts 2-4 underwent plasmapheresis before redosing; cohort 5 was redosed without plasmapheresis. We analyzed safety, immune response (humoral and cell-mediated responses and complement activation), and vector genome distribution. After 2 or 3 plasmapheresis exchanges, circulating anti-AAVrh74 antibodies were reduced, and animals were redosed. Plasmapheresis was well tolerated, with no abnormal clinical or immunological observations. Cohort 5 (redosed with high anti-AAVrh74 antibody titers) had hypersensitivity reactions, which were controlled with treatment. These findings suggest that plasmapheresis is a safe and effective method to reduce anti-AAV antibody levels in nonhuman primates prior to gene transfer therapy. The results may inform human studies involving redosing or circumvention of pre-existing immunity.
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Affiliation(s)
| | | | | | | | - Sarah Lewis
- Sarepta Therapeutics, Inc., Cambridge, MA 02142, USA
| | - Kyle Cochran
- Sarepta Therapeutics, Inc., Cambridge, MA 02142, USA
| | - Jerry R. Mendell
- Center for Gene Therapy, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Pediatrics and Neurology, The Ohio State University, Columbus, OH 43210, USA
| | - Louise R. Rodino-Klapac
- Sarepta Therapeutics, Inc., Cambridge, MA 02142, USA
- Center for Gene Therapy, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Pediatrics and Neurology, The Ohio State University, Columbus, OH 43210, USA
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9
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Mitarnun W, Kongngern L, Tantisungvarakoon P, Boonsayomphu T, Tianchetsada N, Potchanapong T. Plasmapheresis in post-COVID-19 myelitis: A case report. Qatar Med J 2024; 2024:19. [PMID: 38654819 PMCID: PMC11037093 DOI: 10.5339/qmj.2024.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/21/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Previous studies have delineated different neurological manifestations associated with coronavirus disease 2019 (COVID-19). Myelitis is identified as a rare neurological complication resulting from a COVID-19 infection. Limited information is available regarding the treatment of patients experiencing this condition. CASE REPORT This report extracts data from the medical record of a post-COVID-19 myelitis patient at Buriram Hospital and follows up prospectively on the patient's symptoms after treatment. A 61-year-old man, previously vaccinated for COVID-19 and with a history of hypertension and dyslipidemia, experienced progressive bilateral lower-extremity weakness (recorded as muscle strength grade 2/5 in both lower extremities) for 6 weeks. He had a mild case of COVID-19 2 months earlier, which resolved in 10 days without specific treatment. However, 2 weeks after being diagnosed with COVID-19, he developed weakness in his lower limbs, numbness below the nipple, and urinary retention. Spinal magnetic resonance imaging revealed multifocal longitudinal myelitis. Despite initial treatment with methylprednisolone, the patient showed no clinical improvement. Consequently, he underwent five cycles of plasmapheresis. Three months after discharge, a notable improvement was observed, with his muscle strength graded at 4/5 in both lower extremities and the resolution of sensory and urinary symptoms. CONCLUSIONS We presented the case of a COVID-19-vaccinated patient, in whom COVID-19 infection might have led to myelitis. We found promising results in treating prolonged COVID-19-related myelitis symptoms through the use of plasmapheresis.
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Affiliation(s)
- Witoon Mitarnun
- Neurology Unit, Department of Internal Medicine, Buriram Hospital, Buriram, Thailand
| | - Lisa Kongngern
- Neurology Unit, Department of Internal Medicine, Buriram Hospital, Buriram, Thailand
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10
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Rangsrisaeneepitak V, Tekarnjnavanit A, Kanjanapipatkul P, Koowattanatianchai S. The Response of Osmotic Demyelination Syndrome to Plasmapheresis in a Patient Presenting with Catatonia after Correction of Hyponatraemia in Hyperemesis Gravidarum. Eur J Case Rep Intern Med 2024; 11:004373. [PMID: 38584910 PMCID: PMC10997398 DOI: 10.12890/2024_004373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/19/2024] [Indexed: 04/09/2024] Open
Abstract
Osmotic demyelination syndrome (ODS) is a disorder characterised by the widespread development of demyelination in both pontine and extrapontine regions. It has been recognised as a complication arising from the rapid correction of hyponatraemia. This study presents the case of a 20-year-old Thai female patient at 10 weeks gestation, exhibiting an initial presentation of catatonia - an uncommon manifestation of ODS. The patient developed symptoms following the rapid correction of hyponatraemia in the context of hyperemesis gravidarum. Magnetic resonance imaging (MRI) of the brain revealed a trident or bat-wing-shaped pattern in T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences at the central pons. The patient underwent five cycles of plasmapheresis and received rehabilitation, leading to clinical improvement. LEARNING POINTS Osmotic demyelination syndrome (ODS) is a rare but potentially devastating neurological complication, such as catatonia, resulting from the correction of hyponatraemia.Pregnancies complicated by hyperemesis gravidarum tend to exhibit hyponatraemia and hypokalaemia, which serve as contributing risk factors for ODS.Plasmapheresis is considered as an option in the treatment of ODS for the removal of inflammatory substances.
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Spillers NJ, Luther PM, Talbot NC, Kidder EJ, Doyle CA, Lutfallah SC, Derouen AG, Tirumala S, Ahmadzadeh S, Shekoohi S, Kaye AD, Varrassi G. A Comparative Review of Typical and Atypical Optic Neuritis: Advancements in Treatments, Diagnostics, and Prognosis. Cureus 2024; 16:e56094. [PMID: 38618469 PMCID: PMC11009899 DOI: 10.7759/cureus.56094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
Optic neuritis (ON) is a debilitating condition that through various mechanisms, including inflammation or demyelination of the optic nerve, can result in partial or total permanent vision loss if left untreated. Accurate diagnosis and promptly initiated treatment are imperative related to the potential of permanent loss of vision if left untreated, which can lead to a significant reduction in the quality of life in affected patients. ON is subtyped as "typical" or "atypical" based on underlying causative etiology. The etiology of ON can be differentiated when appropriate diagnostic testing is performed. Using history taking, neuroimaging, and visual testing to localize the underlying pathology of ON in a time-sensitive manner is critical in mitigating these unsatisfactory outcomes. Herein, we examine the differences in presentation, pathophysiology, and treatments of typical ON causes, like multiple sclerosis (MS), and atypical causes such as neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin G (IgG) ON. The present investigation places focus on both neuroimaging and visual imaging in the differentiation of ON. Additionally, this review presents physicians with a better understanding of different presentations, treatments, and prognoses of ON.
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Affiliation(s)
- Noah J Spillers
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Patrick M Luther
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Norris C Talbot
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Evan J Kidder
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Connor A Doyle
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Salim C Lutfallah
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, USA
| | - Alyssa G Derouen
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sridhar Tirumala
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Fouad MM, Zawilla NH, Abdelsamie AA, Manawil M, Shehata RSA, Mohammed RS, Khalifa EM, Abdallah Ramadan M, Mourad BH. Successful Management of Severe Unresponsive Snake Bite Envenomation Using Plasmapheresis and Corticosteroid at Egyptian National Environmental and Clinical Toxicology Research Center: A Case Report. Wilderness Environ Med 2024; 35:82-87. [PMID: 38379491 DOI: 10.1177/10806032231225102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Snakebite is a significant public health issue in which venom-induced consumption coagulopathy is a common and serious complication that results from the activation of the coagulation pathway by snake toxins. We report a male patient, 56 y old, who was thought to have been bitten by a snake on his left foot. He was transported to a nearby hospital where he received analgesics and 3 snake polyvalent antivenom vials, and then he was transported to our hospital after 12 h. He presented with 2 small puncture wounds, pain, blistering, and edema of the left foot. On the 2nd day, the patient developed gingival bleeding and hematuria. Laboratory investigations upon admission revealed prothrombin time (PT) of more than 3 min, prothrombin concentration (PC) of less than 2.5%, and an international normalized ratio (INR) of 23.43. Further investigation of urine showed more than 100 RBCs. Despite receiving 16 packs of plasma and 40 snake polyvalent antivenom vials manufactured by VACSERA over 3 days, hemoglobin concentration and platelet count decreased with the appearance of jaundice, lactate dehydrogenase was 520, and reticulocytes were 3.5%. PT was more than 300 s, and INR was still over range. Plasmapheresis and corticosteroids were provided, which improved the patient's general condition, PT, PC, and INR, and the patient was discharged after 6 days of hospital stay. This case report indicated that plasmapheresis and corticosteroids were clinically efficient approaches in the management of snake envenomation unresponsive to antivenom.
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Affiliation(s)
- Marwa Mohammed Fouad
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nermin Hamdy Zawilla
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
- Head of National Environmental and Clinical Toxicological Research Centre (NECTR), Cairo University, Cairo, Egypt
| | - Aiesha Ashraf Abdelsamie
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Marie Manawil
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Rateba Said Mohammed
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Mahmoud Khalifa
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona Abdallah Ramadan
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Basma Hussein Mourad
- Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Garg P, Lakhey K, Mishra N, Buccha Y, Deo KS. Navigating Treatment Dilemmas: Recalcitrant Pemphigus and the Burden of Multiple Comorbidities. Cureus 2024; 16:e56357. [PMID: 38633948 PMCID: PMC11022114 DOI: 10.7759/cureus.56357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2024] [Indexed: 04/19/2024] Open
Abstract
Pemphigus vulgaris is a chronic autoimmune disease of the skin caused by the production of autoantibodies targeting desmogleins 1 and 3 usually presenting in individuals with an average age of onset of approximately 40 years. A 35-year-old obese, diabetic woman presented with fluid-filled lesions over her body for three months along with erosions and painful ulcers in her mouth and genital area for two months. Based on clinical and histopathological studies, the patient was diagnosed as a case of pemphigus vulgaris. She was started on conventional treatment with oral corticosteroids followed by pulse therapy and mycophenolate mofetil. Rituximab infusion was scheduled but could not be administered due to elevated D-dimer values. The patient underwent screening for deep vein thrombosis (DVT) and received subcutaneous enoxaparin and oral rivaroxaban. She developed severe sepsis for which she was treated with systemic antibiotics. She subsequently developed acute renal failure and underwent hemodialysis. The patient's clinical condition further deteriorated, which necessitated therapeutic plasma exchange (TPE). Collagen, colloidal silver, and silicone foam dressings were done to hasten wound healing. Two distinct approaches were employed to eliminate the pseudomembrane on the wounds. One portion was treated with hydrogen peroxide (H2O2), while the other was with hyaluronidase. The hyaluronidase treatment resulted in considerable improvement of the lesions. Intravenous immunoglobulin (IVIG) infusion was scheduled. However, the treatment could not be administered as the patient succumbed to death due to pulmonary thromboembolism (PTE) secondary to DVT.
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Affiliation(s)
- Priya Garg
- Dermatology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Kshitiz Lakhey
- Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Nishtha Mishra
- Dermatology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Yash Buccha
- Dermatology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Kirti S Deo
- Dermatology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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14
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Raina R, Jothi S, Haffner D, Somers M, Filler G, Vasistha P, Chakraborty R, Shapiro R, Randhawa PS, Parekh R, Licht C, Bunchman T, Sethi S, Mangat G, Zaritsky J, Schaefer F, Warady B, Bartosh S, McCulloch M, Alhasan K, Swiatecka-Urban A, Smoyer WE, Chandraker A, Yap HK, Jha V, Bagga A, Radhakrishnan J. Post-transplant recurrence of focal segmental glomerular sclerosis: consensus statements. Kidney Int 2024; 105:450-463. [PMID: 38142038 DOI: 10.1016/j.kint.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/25/2023]
Abstract
Focal segmental glomerular sclerosis (FSGS) is 1 of the primary causes of nephrotic syndrome in both pediatric and adult patients, which can lead to end-stage kidney disease. Recurrence of FSGS after kidney transplantation significantly increases allograft loss, leading to morbidity and mortality. Currently, there are no consensus guidelines for identifying those patients who are at risk for recurrence or for the management of recurrent FSGS. Our work group performed a literature search on PubMed/Medline, Embase, and Cochrane, and recommendations were proposed and graded for strength of evidence. Of the 614 initially identified studies, 221 were found suitable to formulate consensus guidelines for recurrent FSGS. These guidelines focus on the definition, epidemiology, risk factors, pathogenesis, and management of recurrent FSGS. We conclude that additional studies are required to strengthen the recommendations proposed in this review.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Swathi Jothi
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Michael Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Prabhav Vasistha
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, New York, New York, USA
| | - Parmjeet S Randhawa
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rulan Parekh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher Licht
- Division of Pediatric Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Bunchman
- Pediatric Nephrology and Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Guneive Mangat
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Joshua Zaritsky
- Division of Pediatric Nephrology, Nemours, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Sharon Bartosh
- Department of Pediatrics, University of Wisconsin Medical School, Madison, Wisconsin, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Khalid Alhasan
- Nephrology Unit, Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Pediatric Kidney Transplant Division, Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Agnieszka Swiatecka-Urban
- University of Virginia Children's Hospital, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William E Smoyer
- Center for Clinical and Translational Research and Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anil Chandraker
- Transplantation Research Center, Kidney and Pancreas Transplantation, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Arvind Bagga
- Division of Pediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Jai Radhakrishnan
- Department of Medicine (Nephrology), Columbia University Medical Center, New York, New York, USA.
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15
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Balakrishnan N, Beaini H, Carter S, Araj FG. Bedside popliteal vein cannulation for simultaneous plasmapheresis and renal replacement therapy in the prone position. J Invasive Cardiol 2024. [PMID: 38422530 DOI: 10.25270/jic/24.00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Naveen Balakrishnan
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas; USA
| | - Hadi Beaini
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Spencer Carter
- University of Utah, Division of Cardiovascular Medicine, Salt Lake City, Utah, USA
| | - Faris G Araj
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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16
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R R, Routray M. Management of Yellow Phosphorus-Induced Acute Liver Failure: A Case Report and Review of Literature. Cureus 2024; 16:e54223. [PMID: 38496055 PMCID: PMC10943409 DOI: 10.7759/cureus.54223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Three percent (3%) of yellow phosphorus is the active component of the rodenticide Ratol®. It is a potent hepatotoxin that leads to acute liver failure (ALF) with high mortality. There is no antidote available; the only definitive management is liver transplantation. Therapeutic plasma exchange, or plasmapheresis, appears to help these patients by removing the toxin, its metabolite, or the inflammatory mediators released in the body in response to the toxin. Here, we report a case of a 19-year-old male with an alleged history of Ratol® ingestion and ALF with acute kidney injury. He had a complete reversal of his condition with timely intervention in the form of plasmapheresis.
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Affiliation(s)
- Rohini R
- Medicine, All India Institute of Medical Sciences, Raipur, IND
| | - Manender Routray
- General Medicine, All India Institute of Medical Sciences, Raipur, IND
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17
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Konno S, Fujioka T. Serum immunoglobulin G level reduction is a predictor of short-term improvement in patients with myasthenia gravis undergoing plasmapheresis. Ther Apher Dial 2024; 28:131-140. [PMID: 37731293 DOI: 10.1111/1744-9987.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 05/13/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES The aim of the study was to investigate the serological factors in predicting symptom improvement in myasthenia gravis (MG) patients who underwent plasmapheresis (PP). METHODS The relationship between symptom improvement and change in immunoglobin G (IgG) and acetylcholine receptor antibody (AchR-Ab) levels in 21 MG patients after PP was analyzed. RESULTS Patients were divided into two groups: the favorable (n = 11) or unfavorable (n = 10) response groups around the median MG composite improvement rate (50 [29, 56]%) 2 weeks after a PP course. In all patients, the IgG reduction rate before and after PP was higher in the favorable than the unfavorable response group. In AChR-Ab-positive patients, IgG and AChR-Ab reduction rates were higher in the favorable than the unfavorable response group. CONCLUSION IgG reduction rate is a predictor of symptom improvement in MG patients who underwent PP.
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Affiliation(s)
- Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Toshiki Fujioka
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
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18
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Fjellbirkeland OW, Szpirt WM, Børresen ML. The role of plasmapheresis in severe acute disseminated encephalomyelitis with clinical findings of transverse myelitis. Ther Apher Dial 2024; 28:119-124. [PMID: 37646345 DOI: 10.1111/1744-9987.14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Acute disseminated encephalomyelitis is a rare acute demyelinating disease of the central nervous system (CNS). The pathogenesis remains unclear but is suspected to be autoimmune. High doses of methylprednisolone (HDMP) are currently considered standard of treatment. Plasmapheresis (PE) is typically given in steroid refractory cases. There is currently limited evidence supporting its use in ADEM. MATERIALS AND METHODS We report a 16-year-old girl with ADEM who improved rapidly after initiating PE. RESULTS The patient presented with acute onset of multifocal CNS symptoms, including encephalopathy, requiring intensive care unit management. Despite HDMP administration, her clinical condition continued to deteriorate. PE was therefore initiated on the same day as HDMP. Her clinical condition improved significantly following the first session. She was extubated and discharged from the intensive care unit the following day. CONCLUSION HDMP combined with PE may be an effective first-line treatment in patients with fulminant ADEM.
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Affiliation(s)
| | - Wladimir M Szpirt
- Department of Nephrology, Plasmapheresis Services, Copenhagen, Denmark
| | - Malene L Børresen
- Department of Pediatrics and Adolescent Medicine, Copenhagen, Denmark
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19
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Nazir Z, Habib A, Ali T, Shafiq Khan K, Abbas Jaffri S, Haque MA. Co-occurrence of Guillain-Barre syndrome and rheumatoid arthritis in a young female: A case report from a low middle-income country. Clin Case Rep 2024; 12:e8481. [PMID: 38333652 PMCID: PMC10849983 DOI: 10.1002/ccr3.8481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/10/2024] Open
Abstract
Key Clinical Message We present the case of an adult female who had rheumatoid arthritis at first but later tested positive for Guillain-Barré syndrome (GBS). In symptomatic GBS patients (related to large joints), physicians (and therapists) should consider rheumatoid arthritis when risk factors are present. Abstract The co-existence of GBS and other autoimmune disorders is uncommon. We present the case of an adult female who had rheumatoid arthritis at first but later tested positive for GBS. Further details are provided regarding the interdisciplinary diagnostic and therapy strategy that led to the patient's complete recovery. An adult female patient with rheumatoid arthritis presented with progressive weakness in her lower limbs, affecting her arm and causing numbness in her left hand and bilateral lower limbs. She has not passed stool for the last 2 days and has experienced gastroenteritis with watery, profuse diarrhea. On admission, the patient was awake, alert, and able to communicate. She had a thorough history of vital signs, with no signs of dehydration, jaundice, pallor, or edema. The patient's lower limbs were hypotonic and her upper limbs were normal. She experienced loss of sensation in her lower limbs, vibration, and proprioception. The patient's EMG-NCS report indicated sensory and motor axonal neuropathy (AMSAN variant). Plasmapheresis sessions were finished in our patient, and a very good result was achieved. In symptomatic GBS patients (related to large joints), physicians (and therapists) should consider rheumatoid arthritis when risk factors are present. Appropriate clinical treatment, which includes prompt evaluation of alternate diagnoses in the case of therapeutic failure, can improve patient outcomes.
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Affiliation(s)
- Zainab Nazir
- Dow University of Health SciencesKarachiPakistan
| | - Ashna Habib
- Dow University of Health SciencesKarachiPakistan
| | - Tooba Ali
- Dow University of Health SciencesKarachiPakistan
| | | | | | - Md Ariful Haque
- Department of Public HealthAtish Dipankar University of Science and TechnologyDhakaBangladesh
- Voice of Doctors Research SchoolDhakaBangladesh
- Department of Orthopaedic SurgeryYan'an Hospital Affiliated to Kunming Medical UniversityKunmingYunnanChina
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20
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Hoad VC, Castrén J, Norda R, Pink J. A donor safety evidence literature review of the short- and long-term effects of plasmapheresis. Vox Sang 2024; 119:94-101. [PMID: 37641582 DOI: 10.1111/vox.13512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023]
Abstract
Many blood establishments are expanding plasmapheresis collection capacity to achieve increasing plasma for fractionation volume targets, driven by immunoglobulin product demand. Some adverse events occur in both apheresis and whole blood collection, such as venepuncture-related trauma and vasovagal reactions. Others are specifically related to the apheresis procedure, such as citrate reactions, haemolysis, infiltration and air embolism. Whilst plasmapheresis procedures are generally well tolerated, theoretical longer term donor health considerations, such as the effects on donor plasma protein levels, bone mineral density, iron deficiency and malignancy also require consideration. An evidence-based framework that supports a safe and sustainable increase in the collection of plasma is essential. Our review demonstrates a lack of high-quality evidence on risks and outcomes specifically in plasmapheresis. Whilst conservative procedural controls and donor harm minimization policies will mitigate risk, high-quality evidence is needed to facilitate practice change that is safe and sustainable and maximizes the potential of individual donor differences.
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Affiliation(s)
- Veronica C Hoad
- Donor and Product Safety (DAPS) Policy Unit, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
| | | | - Rut Norda
- Clinical Immunology and Transfusion Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Joanne Pink
- Donor and Product Safety (DAPS) Policy Unit, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
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21
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Mohy-ud-din N, Jonassaint N. Severe Liver and Renal Injury From Tribulus Terrestris. ACG Case Rep J 2024; 11:e01267. [PMID: 38328764 PMCID: PMC10849413 DOI: 10.14309/crj.0000000000001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024] Open
Abstract
Tribulus terrestris is a shrub that is found worldwide. Although it has been linked to severe jaundice and death in grazing animals, there are only a few case reports of hepatotoxicity in humans. We describe a case of a 46-year-old man who took tribulus supplements daily for 2 months. He developed severe jaundice prompting hospital admission. His total bilirubin peaked at 48 mg/dL, with concomitant renal dysfunction (creatinine of 7.1). His liver biopsy showed features consistent with drug-induced liver injury. He was initiated on a trial of plasmapheresis and underwent 3 sessions with a subsequent decrease in bilirubin with each session. He had appropriate renal recovery and was discharged home and on follow-up, continues to do well with most recent bilirubin of 1.1 mg/dL.
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Affiliation(s)
- Nabeeha Mohy-ud-din
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Naudia Jonassaint
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA
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22
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Schroyens N, D'aes T, De Buck E, Mikkelsen S, Tiberghien P, van den Hurk K, Erikstrup C, Compernolle V, Van Remoortel H. Safety and protection of plasma donors: A scoping review and evidence gap map. Vox Sang 2024; 119:110-120. [PMID: 37814964 DOI: 10.1111/vox.13544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND AND OBJECTIVES As part of a large-scale project to safely increase plasma collection in Europe, the current scoping review identifies the existing evidence (gaps) on adverse events (AEs) and other health effects in plasmapheresis donors, as well as factors that may be associated with such events/effects. MATERIALS AND METHODS We searched six databases and three registries. Study characteristics (publication type, language, study design, population, outcomes, associated factors, time of assessment, duration of follow-up, number and frequency of donations, convalescent plasma [y/n], setting and location) were synthesized narratively and in an interactive evidence gap map (EGM). RESULTS Ninety-four research articles and five registrations were identified. Around 90% were observational studies (57 controlled and 33 uncontrolled), and most of them were performed in Europe (55%) or the United States (20%). Factors studied in association with donor health included donor characteristics (e.g., sex, age) (n = 27), cumulative number of donations (n = 21), donation frequency (n = 11), plasma collection device or programme (n = 11), donor status (first time vs. repeat) (n = 10), donation volume per session (n = 8), time in donation programme (n = 3), preventive measures (n = 2) or other (n = 9). CONCLUSION The current scoping review provides an accessible tool for researchers and policymakers to identify the available evidence (gaps) concerning plasmapheresis donation safety. Controlled prospective studies with long-term donor follow-up are scarce. Furthermore, additional experimental studies comparing the health effects of different donation frequencies are required to inform a safe upper limit for donation frequency.
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Affiliation(s)
- Natalie Schroyens
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Tine D'aes
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Susan Mikkelsen
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Pierre Tiberghien
- Etablissement Français du Sang, Saint-Denis, France
- Université de Franche-Comté, EFS, INSERM, UMR Right, Besançon, France
| | - Katja van den Hurk
- Donor Medicine Research - Donor Studies, Sanquin Research, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Veerle Compernolle
- Belgian Red Cross, Blood Services, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Watanabe K, Ohashi S, Watanabe T, Kakinuma Y, Kinno R. Case report: Recovery from refractory myasthenic crisis to minimal symptom expression after add-on treatment with efgartigimod. Front Neurol 2024; 15:1321058. [PMID: 38318438 PMCID: PMC10838969 DOI: 10.3389/fneur.2024.1321058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Myasthenic crisis, a life-threatening exacerbation of myasthenia gravis, is a significant clinical challenge, particularly when refractory to standard therapies. Here, we described a case of myasthenic crisis in which the patient transitioned from refractory myasthenic crisis to minimal symptom expression after receiving add-on treatment with efgartigimod, a novel neonatal Fc receptor antagonist. A 54 years-old woman who was diagnosed with anti-acetylcholine receptor antibody-positive myasthenia gravis experienced respiratory failure necessitating mechanical ventilation. Despite aggressive treatment with plasmapheresis, intravenous immunoglobulins, and high-dose corticosteroids, her condition continued to deteriorate, culminating in persistent myasthenic crisis. Efgartigimod was administered as salvage therapy. Remarkable improvement in neuromuscular function was observed within days, allowing for successful weaning from mechanical ventilation. Over the subsequent weeks, the patient's symptoms continued to ameliorate, ultimately reaching a state of minimal symptom expression. Serial assessments of her serum anti-acetylcholine receptor antibody titer showed a consistent decline in parallel with this clinical improvement. This case highlights efgartigimod's potential as an effective therapeutic option for refractory myasthenic crisis, offering new hope for patients facing this life-threatening condition.
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Affiliation(s)
- Keiko Watanabe
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shinichi Ohashi
- Respiratory Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Takuya Watanabe
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuki Kakinuma
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Ryuta Kinno
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
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24
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Dhillon M, Kobashigawa JA, Kittleson M, Jain R, Patel N, Singer-Englar T, Zhang X, Hakimi M, Aintablian T, Vescio R, Dilibero D, Kransdorf E, Czer L, Nikolova AP, Patel JK. Does bortezomib influence pre-transplant desensitization therapy or benefit post-heart transplant outcomes for highly sensitized patients? Clin Transplant 2024; 38:e15165. [PMID: 37837612 DOI: 10.1111/ctr.15165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The use of bortezomib which is a proteasome inhibitor has been demonstrated to be efficacious in small number of patients as a desensitization strategy in heart transplant. We reviewed our single center's experience using Bortezomib along with plasmapheresis as desensitization therapy for highly sensitized patients to assess pre- and post-transplant outcomes. METHOD We assessed 43 highly sensitized patients awaiting HTx (defined as cPRA > 50%) between 2010 and 2021 who underwent desensitization therapy with bortezomib. Only those patients who subsequently underwent HTx were included in this study. Enrolled patients received up to four doses of bortezomib (1.3 mg/m2 ) over 2 weeks in conjunction with plasmapheresis. The efficacy of PP/BTZ was assessed by comparing the calculated panel reactive antibodies to HLA class I or class II antigens. Post-transplant outcomes including overall survival and incidence of rejection were compared to those of non-sensitized patients (PRA < 10%, n = 649) from the same center. RESULTS The average cPRA prior to PP/BTZ was 94.5%. Post-PP/BTZ there was no statistically significant decline in mean cPRA, class I cPRA, or class II cPRA, though the average percentage decrease in class I cPRA (8.7 ± 17.0%) was higher than the change in class II cPRA (4.4 ± 13.3%). Resulted were also replicated with C1q-binding antibodies showing more effect on I class compared to class II (15.0 ± 37.4% vs. 6.8 ± 33.6%) as well as with 1:8 dilutional assay (14.0 ± 23.0% vs. 9.1 ± 34.9%). Additionally, PP/BTZ treated patients and the control group of non-sensitized patients had similar overall 1 year survival (95.4 vs. 92.5%) but patients with PP/BTZ had increased incidence of AMR (79.1% vs. 97.1%, p = < .001), any treated rejection (62.8% vs. 86.7%, p = < .001) and de novo DSA development (81.4% vs. 92.5%, p = .007). Major side effects of PP/BTZ included thrombocytopenia (42%), infection requiring antibiotics (28%), and neuropathy (12%). CONCLUSION The use of bortezomib in highly sensitized patients does not significantly lower circulating antibodies prior to heart transplantation. However, its use may improve the chances of obtaining an immuno-compatible donor heart and contribute to acceptable post-transplant outcomes.
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Affiliation(s)
- Manvir Dhillon
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | | | - Rashmi Jain
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Nikhil Patel
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Xiaohai Zhang
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Matthew Hakimi
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Robert Vescio
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Evan Kransdorf
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Lawrence Czer
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
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Piplani S, Jain A, Singh K, Gulati S, Chaturvedi S, Bejugam VR, Brown D, Asuzu C, Kolli ST, Shah U, Reet J, Mihajlovic M, Jelic V, Jelic G, Roberts RSD, Damania D, Radulovic M. Efficacy and adverse effects of insulin versus plasmapheresis in patients with hypertriglyceridemia-3-induced acute pancreatitis: a systematic review and meta-analysis. Ann Gastroenterol 2024; 37:109-116. [PMID: 38223249 PMCID: PMC10785016 DOI: 10.20524/aog.2023.0849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 10/03/2023] [Indexed: 01/16/2024] Open
Abstract
Background Hypertriglyceridemia is a common cause of acute pancreatitis (AP). This literature review compared the effectiveness and adverse events of insulin therapy, with or without heparin, and plasmapheresis, in reducing triglyceride levels in patients with hypertriglyceridemia-induced AP. Methods Systematic reviews, meta-analyses, evidence syntheses, editorials, commentaries, protocols, abstracts, theses and preprints were excluded. Review Manager was used to conduct the meta-analysis. The literature search yielded 2765 articles, but only 5 were included in the systematic review and meta-analysis and the total number of participants in the review was 269. Results From this study's analysis, insulin ± heparin was more successful in reducing triglyceride levels than plasmapheresis (standardized mean difference -0.37, 95% confidence interval [CI] 0.99 to 0.25; P=0.25). Insulin ± heparin therapy had a lower mortality rate than plasmapheresis (risk ratio [RR] 0.70, 95%CI 0.25-1.95). Hypotension, hypoglycemia, and acute renal failure were less common in the plasmapheresis therapy group than in insulin ± heparin therapy (RR 1.13, 95%CI 0.46-2.81, RR 3.90, 95%CI 0.45-33.78, and RR 0.48, 95%CI 0.02-13.98 for hypotension, hypoglycemia, and acute renal failure, respectively). Conclusions This study found no significant difference in mortality between insulin ± heparin therapy and plasmapheresis used for the reduction in triglyceride levels. It is notable that no substantial differences were observed in the most common side-effects encountered during these therapies, thus indicating non-inferiority.
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Affiliation(s)
- Shobhit Piplani
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Arpit Jain
- Department of Emergency Medicine, All India Institute of Medical Sciences, Delhi, India (Shobhit Arpit Jain)
| | - Kamaldeep Singh
- Department of Cardiology, Government Medical College and Hospital, Chandigarh, India (Kamaldeep Singh)
| | - Shreya Gulati
- Department of Internal Medicine, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India (Shreya Gulati)
| | - Salil Chaturvedi
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Vishal Reddy Bejugam
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Donclair Brown
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Chisom Asuzu
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Shiny Teja Kolli
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Usman Shah
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Jashan Reet
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Milos Mihajlovic
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Vladimir Jelic
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Gavro Jelic
- Department of Internal Medicine, James J. Peters VA Medical Center, Icahn School of Medicine, Bronx, NY, USA (Gavro Jelic, Miroslav Radulovic)
| | - Rosalba Santana De Roberts
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Dushyant Damania
- Department of Internal Medicine, Jacobi Medical Center/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, Bronx, NY, USA (Shobhit Piplani, Salil Chaturvedi, Vishal Reddy Bejugam, Donclair Brown, Chisom Asuzu, Shiny Teja Kolli, Usman Shah, Jashan Reet, Milos Mihajlovic, Vladimir Jelic, Rosalba Santana De Roberts, Dushyant Damania)
| | - Miroslav Radulovic
- Department of Internal Medicine, James J. Peters VA Medical Center, Icahn School of Medicine, Bronx, NY, USA (Gavro Jelic, Miroslav Radulovic)
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Orabueze I, Sheikh H, Cluzet V. Pulmonary Renal Syndrome in ANCA-Negative Vasculitis. Cureus 2024; 16:e52491. [PMID: 38370990 PMCID: PMC10874128 DOI: 10.7759/cureus.52491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/20/2024] Open
Abstract
Below we highlight a rare case of anti-neutrophil cytoplasmic antibody (ANCA)-negative vasculitis, unique in its own right, as the diagnosis was hard to make and the respiratory decline rapid, with the patient going from a 23% fraction of inspired oxygen (FiO2) on admission to 100% FiO2 within four days for what was initially presumed to be community-acquired pneumonia. Precise data on the incidence or prevalence of ANCA-associated vasculitis are lacking. However, a 20-year population-based study in the United States found that, of 58 incident cases, 9% were ANCA-negative. We present the case of a 69-year-old Egyptian male with worsening shortness of breath who was found to have elevated inflammatory markers and an ANCA-negative panel and was later diagnosed with ANCA-negative vasculitis. By highlighting this case, we aim to increase awareness and point out the need to keep the disease high on the list of differential diagnoses in order to allow for timely intervention. Though there isn't a lot of data available on definitive treatment or the disease itself, there are studies that point to rituximab, cyclophosphamide, plasmapheresis, and hemodialysis as useful interventions for treatment.
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Affiliation(s)
- Ijeoma Orabueze
- Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, USA
| | - Hira Sheikh
- Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, USA
| | - Valerie Cluzet
- Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, USA
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Anderson ZJ, Avula S, Kumar A, Sarkar D, LaFave L. Graves' Disease-Induced Psychosis Refractory to Intensive Medical Management Requiring Non-voluntary Thyroidectomy for Psychosis Resolution: A Case Report. Cureus 2024; 16:e51547. [PMID: 38313905 PMCID: PMC10834884 DOI: 10.7759/cureus.51547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 02/06/2024] Open
Abstract
Graves' disease is an autoimmune disorder characterized by hyperthyroidism, ophthalmopathy, and dermatopathy. The chief thyroid hormone abnormality is the elevation of thyroid hormone, resulting in an overexcitation of the sympathetic and central nervous systems. Psychosis due to Graves' disease is rarely the first presenting symptom, but it is an essential complication of those with severe or untreated disease. Most patients respond well to standard medical management for Graves' disease, although there exists a small subset of people who do not. There are few cases describing patients with psychosis without underlying psychiatric disorders who require intensive care admission and thyroidectomy for necessary management of refractory psychosis secondary to thyrotoxicosis. Here, we present a case of a patient without medical or surgical history who presented with severe psychosis due to untreated Graves' disease requiring non-voluntary thyroidectomy for definitive management.
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Affiliation(s)
| | - Sreekant Avula
- Diabetes, Endocrinology, and Metabolism, University of Minnesota, Minneapolis, USA
| | - Ameya Kumar
- Internal Medicine, Hennepin County Medical Center, Minneapolis, USA
| | - Deepon Sarkar
- Internal Medicine, Hennepin County Medical Center, Minneapolis, USA
| | - Laura LaFave
- Endocrinology and Diabetes, Hennepin County Medical Center, Minneapolis, USA
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Aljezani MA, Althubaiti F, Alhamed L, Alharthi A, Alamoodi A, Bakheet Y, Badawi M, Hindawi S. Plasma Exchange in Pediatric Neurology Patients: A Single-Center Experience. Cureus 2024; 16:e52691. [PMID: 38384617 PMCID: PMC10879651 DOI: 10.7759/cureus.52691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is a procedure involving the filtration of a patient's plasma to eliminate pathogenic components or address deficiencies. This technique finds varied indications in the pediatric age group, particularly in neuroinflammatory diseases. OBJECTIVES The objective of this study is to delve into our local experience with TPE, focusing on indications, outcomes, and complications among children with neurological diseases at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. RESULTS Conducted at the pediatric department of KAUH in Jeddah from November 2008 to July 2023, this retrospective cohort study examined 15 patients, revealing a notable male predominance with 12 male patients (80%) and three female patients (20%). About two-thirds of patients exhibited an average illness severity, with a Glasgow Coma Scale (GCS) score of 10.7 and an Expanded Disability Status Scale (EDSS) score of 4.8. The median length of hospital stay was 23 days, and in the pediatric intensive care unit (PICU), it was 8.5 days. Presenting symptoms included limb weakness (n = 6), loss of consciousness (n = 3), dysphagia (n = 3), photophobia (n = 1), and ascending paralysis (n = 1). The TPE was performed for Guillain-Barré syndrome (GBS) (n = 7), myasthenia gravis (MG) (n = 3), transverse myelitis (TM) (n = 2), neuromyelitis optica (NMO) (n = 2), and systemic lupus erythematosus (SLE) cerebritis (n = 1). Twelve patients were admitted to the PICU, and mechanical ventilation was required for 10 patients. In magnetic resonance imaging (MRI) findings, abnormalities were observed in 10 cases, while the remaining five either had normal results or did not undergo MRI. Most patients required five sessions of TPE (n = 7). The median age at the initiation of TPE was 13 years. Twelve patients improved with TPE treatment, while three did not. Complications observed during and following TPE included fever (n = 5), electrolyte disturbance (n = 5), hypotension (n = 3), hypocalcemia (n = 2), bradycardia (n = 2), vomiting (n = 1), tachycardia (n = 1), eye rash (n = 1), infection (n = 1), and bleeding originating from the TPE procedure site (n = 1). CONCLUSION In conclusion, our study underscores the significance of TPE as a therapeutic modality, emphasizing the imperative for ongoing research to fully exploit its potential across diverse medical contexts for enhancing patient care. Our findings, consistent with prior research, reveal plasma exchange's (PLEX's) wide-ranging applications and complications in neurological disorders.
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Affiliation(s)
- Maram A Aljezani
- Pediatric Neurology, King Abdulaziz University Hospital (KAUH), Jeddah, SAU
- Pediatric Neurology, King Fahad Medical City (KFMC), Riyadh, SAU
| | | | | | | | | | | | - Maha Badawi
- Hematology, King Abdulaziz University, Jeddah, SAU
| | - Salwa Hindawi
- Hematology/Blood Transfusion Services, King Abdulaziz University, Jeddah, SAU
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29
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Hussein G, Liu B, Yadav SK, Warsame M, Jamil R, Surani SR, Khan SA. Plasmapheresis in the ICU. Medicina (Kaunas) 2023; 59:2152. [PMID: 38138254 PMCID: PMC10744423 DOI: 10.3390/medicina59122152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient's plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. This paper provides a brief review of the principles, current applications, and potential future directions of TPE in critical care settings.
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Affiliation(s)
- Guleid Hussein
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Bolun Liu
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Sumeet K. Yadav
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Mohamed Warsame
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Ramsha Jamil
- Sindh Medical College, Jinnah Sindh Medical University, Karachi 75510, Pakistan;
| | - Salim R. Surani
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Syed A. Khan
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
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Peters BJ, Brown AE, Thornton NM, Winters JL, Chalmers SJ. The effect of plasma exchange on serum levels of lacosamide: A case report. Am J Health Syst Pharm 2023; 80:1781-1786. [PMID: 37712141 DOI: 10.1093/ajhp/zxad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE We describe the case of a 22-year-old male who developed thyroid storm necessitating therapeutic plasma exchange (TPE). The patient's past medical history was complicated by epilepsy, for which he took lacosamide. Little evidence was available to guide lacosamide dosing during TPE. Because of an exacerbation of the patient's underlying epilepsy in the context of the thyroid storm, we conducted therapeutic medication monitoring of lacosamide concentrations to guide management. SUMMARY We arranged for measurement of the lacosamide concentration immediately before TPE (5.1 μg/mL) and 2.5 hours after the initial measurement (3.4 μg/mL) to determine the amount of lacosamide removed by TPE. Utilizing population pharmacokinetic parameters, we calculated the expected concentration and compared this to the measured concentration. The difference between these values was used to determine the percentage removed via TPE compared to the expected post-TPE concentration. We found that one TPE session removed an additional 20% of serum lacosamide. CONCLUSION TPE appeared to remove an additional 20% of lacosamide when compared to the expected post-TPE concentration.
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Affiliation(s)
- Bradley J Peters
- Department of Pharmacy, Mayo Clinic Rochester, Rochester, MN, USA
| | - Andrew E Brown
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Nathaniel M Thornton
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Jeffrey L Winters
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Sarah J Chalmers
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
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Ramirez S, Koerich S, Astudillo N, De Gregorio N, Al-Lahham R, Allison T, Rocha NP, Wang F, Soto C. Plasma Exchange Reduces Aβ Levels in Plasma and Decreases Amyloid Plaques in the Brain in a Mouse Model of Alzheimer's Disease. Int J Mol Sci 2023; 24:17087. [PMID: 38069410 PMCID: PMC10706894 DOI: 10.3390/ijms242317087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Alzheimer's disease (AD) is the most common type of dementia, characterized by the abnormal accumulation of protein aggregates in the brain, known as neurofibrillary tangles and amyloid-β (Aβ) plaques. It is believed that an imbalance between cerebral and peripheral pools of Aβ may play a relevant role in the deposition of Aβ aggregates. Therefore, in this study, we aimed to evaluate the effect of the removal of Aβ from blood plasma on the accumulation of amyloid plaques in the brain. We performed monthly plasma exchange with a 5% mouse albumin solution in the APP/PS1 mouse model from 3 to 7 months old. At the endpoint, total Aβ levels were measured in the plasma, and soluble and insoluble brain fractions were analyzed using ELISA. Brains were also analyzed histologically for amyloid plaque burden, plaque size distributions, and gliosis. Our results showed a reduction in the levels of Aβ in the plasma and insoluble brain fractions. Interestingly, histological analysis showed a reduction in thioflavin-S (ThS) and amyloid immunoreactivity in the cortex and hippocampus, accompanied by a change in the size distribution of amyloid plaques, and a reduction in Iba1-positive cells. Our results provide preclinical evidence supporting the relevance of targeting Aβ in the periphery and reinforcing the potential use of plasma exchange as an alternative non-pharmacological strategy for slowing down AD pathogenesis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Claudio Soto
- Mitchell Center for Alzheimer’s Disease and Related Brain Disorders, Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX 77030, USA; (S.R.); (S.K.); (N.A.); (N.D.G.); (R.A.-L.); (T.A.); (N.P.R.); (F.W.)
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32
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Mishra AK, Varma A. Myasthenia Gravis: A Systematic Review. Cureus 2023; 15:e50017. [PMID: 38186498 PMCID: PMC10767470 DOI: 10.7759/cureus.50017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Myasthenia gravis (MG), a rare disease, is the most common neuromuscular junction problem. It's the quintessential autoimmune disease with ocular, bulbar, respiratory, axial, and limb muscles exhibiting a typical fatigable weakening due to the development of antibodies against the acetylcholine receptor (AChR). Infections, stress, surgeries, thymus gland anomalies, and pharmaceutical side effects can also cause it. Ocular symptoms are initially experienced by most of the sufferers. The majority of the sufferers will go through at least one episode of symptom exacerbation during their illness. The immune system in MG interferes with nerve-muscle communication, causing muscles to become weak and tired quickly. The actual cause is not yet known, but a problem in the thymus gland may be the cause. In a person suffering from this disease, the size of the thymus becomes larger than normal, which is also called thymic hyperplasia. It is more common for women to have early-onset MG (EOMG) than for males to have late-onset MG (LOMG). Merely clinical evidence, encompassing the patients' medical history and physical indications of fluctuating muscle weakness in a specific region, is utilized to diagnose MG. Complementary diagnostic procedures and lab techniques aid in confirming the synaptic dysfunction and characterizing its kind and degree. Early diagnosis and the availability of effective treatments have reduced the burden of severe impairment and high mortality previously associated with MG. Current immunomodulation-based therapies come with side effects brought on by persistent immune suppression. Improved knowledge of this relatively uncommon but curable condition is required among primary carers. The objective of this review is to provide information about MG and to help people recognize its symptoms and start treatment without panic so that the progression of this disease can be stopped and complications can be avoided.
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Affiliation(s)
- Aneesh K Mishra
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anuj Varma
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Lewin A, Germain M, Renaud C, Robitaille N, Latour C. Relevance of haemoglobin monitoring in apheresis plasma donors: A retrospective cohort study in Québec, Canada. Vox Sang 2023; 118:1041-1045. [PMID: 37673797 DOI: 10.1111/vox.13523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Systematically measuring pre-donation haemoglobin (Hb) levels might be overly cautious for apheresis plasma donation, since plasmapheresis entails a small loss of red blood cells. We explored the association between the frequency of apheresis plasma donation and capillary blood Hb levels. MATERIALS AND METHODS This retrospective cohort study included donors who gave apheresis plasma at least twice between 24 October 2020 and 23 October 2022 in Québec, Canada. Results were stratified by sex and analysed with linear repeated-measure mixed models with random intercepts. RESULTS In total, 9535 men (mean age = 46.7 years) and 9409 women (mean age = 41.1 years) made ≥2, but no more than 16 apheresis plasma donations. Over an average of 9.2 months of observation, men maintained Hb levels well above the Hb deferral threshold, and their Hb levels decreased by only 0.17 g/dL between the 1st and 15th donation return (p < 0.0001). Over an average of 9.0 months of observation, women also maintained adequate Hb levels, and their Hb levels decreased by 0.08 g/dL between the 1st and 15th donation return. CONCLUSION The frequency of apheresis plasma donation was not associated with clinically meaningful changes in Hb levels, neither in men nor in women. This evidence questions the relevance of systematically monitoring Hb for apheresis plasma donation, at least for donation frequencies of ≤7-8 times per year. However, an adverse impact of plasmapheresis on Hb levels cannot be ruled out for individuals donating more frequently or for longer than ~9 months.
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Affiliation(s)
- Antoine Lewin
- Medical Affairs and Innovation, Héma-Québec, Montréal, Québec, Canada
| | - Marc Germain
- Medical Affairs and Innovation, Héma-Québec, Montréal, Québec, Canada
- Medical Affairs and Innovation, Héma-Québec, Québec, Québec, Canada
| | - Christian Renaud
- Medical Affairs and Innovation, Héma-Québec, Montréal, Québec, Canada
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Karas M, Joseph AM, Ahmad O, Cardenas JM. Acquired Thrombotic Thrombocytopenic Purpura in the Presence of a Urinary Tract Infection: A Rare Pediatric Case. Cureus 2023; 15:e50234. [PMID: 38192908 PMCID: PMC10773685 DOI: 10.7759/cureus.50234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/09/2023] [Indexed: 01/10/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a type of microangiopathic hemolytic anemia that rarely presents in the pediatric population. This life-threatening disorder manifests as severe consumptive thrombocytopenia and disseminated micro-thromboemboli, leading to organ ischemia. Here, we present a case of an acute first-time episode of acquired TTP in a 17-year-old African American female with a past medical history of obesity, recurrent urinary tract infections, and dysfunctional uterine bleeding managed with oral contraceptives. The disorder's insidious onset was only preceded by a urinary tract infection managed as an outpatient with oral cefdinir for four days before symptoms worsened. The patient was admitted to the pediatric intensive care unit with microangiopathic hemolytic anemia, severe thrombocytopenia, low von Willebrand factor-cleaving protease (ADAMTS13) activity, hypofibrinogenemia, gross hematuria, and acute kidney injury. Further workup was significant for a positive urine culture for Escherichia coli. Her hospital course was complicated by an acute ischemic stroke. The patient's TTP was managed by five sessions of plasmapheresis (PLEX), two once-weekly doses of rituximab, five doses of caplacizumab, three doses of high-dose solumedrol, and six days of high-dose prednisone. This regimen led to an overall uptrend in platelet counts toward normal and resolved her kidney injury. Currently, the patient continues to recover as an outpatient with no disability, managed with rituximab and caplacizumab as relapse prophylaxis. This case highlights the need for further investigation into the consideration of TTP as part of the differential diagnosis for pediatric patients presenting with severe thrombocytopenia and acute kidney injury in the absence of a significant medical history. Additionally, the utilization of rituximab, caplacizumab, steroids, and PLEX for TTP in the pediatric population should be further investigated.
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Affiliation(s)
- Monica Karas
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Andrew M Joseph
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Omama Ahmad
- Pediatric Hematology/Oncology, University of Florida College of Medicine, Gainesville, USA
| | - Jose M Cardenas
- Pediatric Critical Care, University of Florida College of Medicine, Gainesville, USA
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Silva Campos JJ, Abels E, Rinder HM, Tormey CA, Jacobs JW. Botulism mimicking Guillain-Barre syndrome: The question of plasma exchange in an unusual case of acute paralysis. J Clin Apher 2023; 38:760-763. [PMID: 37519071 DOI: 10.1002/jca.22081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated polyradiculoneuropathy and the most common cause of acute flaccid paralysis worldwide. GBS classically presents with acute, progressive, ascending weakness, reduced to absent reflexes, and albuminocytological dissociation on cerebrospinal fluid (CSF) analysis. Botulism is a neurotoxin-mediated acute descending flaccid paralysis with cranial nerve palsies and dysautonomia. Botulism in adults is caused by ingestion/inhalation of botulinum toxin or wound infection with Clostridium botulinum. Both GBS and botulism can rapidly precipitate respiratory failure; thus, prompt diagnosis and treatment are crucial to mitigate poor outcomes. Herein, we describe a case of botulism initially diagnosed as GBS given classic laboratory features, and describe the importance of careful consideration of the most appropriate therapeutic modalities in cases of acute flaccid paralysis, particularly regarding empiric administration of botulinum antitoxin and use of intravenous immune globulin in lieu of plasma exchange for potential GBS to prevent removal of antitoxin.
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Affiliation(s)
- Juan J Silva Campos
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Abels
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Jacobs JW, Villalba CAF, Stendahl K, Tormey CA, Abels E. Immunity in the balance: Fatal disseminated adenovirus infection in a patient undergoing plasma exchange and immunosuppressive chemotherapy for anti-glomerular basement membrane disease. J Clin Apher 2023; 38:770-777. [PMID: 37698143 DOI: 10.1002/jca.22088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
Anti-glomerular basement membrane (anti-GBM) disease (formerly known as Goodpasture's syndrome) is a rare autoinflammatory condition that affects the renal and/or pulmonary capillaries. The standard therapeutic regimen for anti-GBM disease involves therapeutic plasma exchange (TPE), cyclophosphamide, and corticosteroids to rapidly remove and inhibit autoantibody production and reduce organ inflammation. Herein we report an 82-year-old female who developed anti-GBM disease but expired despite therapy, secondary to multi-organ failure in the setting of disseminated adenovirus disease. We discuss the utility and potential adverse effect of daily TPE for a protracted course (ie, 10-14 days), the recommended TPE intensity in the 2023 American Society for Apheresis guidelines, updated from every-other-day TPE in the 2019 guidelines, despite no new data. We also highlight the potential for unusual infections to occur in these patients due to the profound immunosuppression, and discuss the importance of balancing immunosuppression to treat the disease with close surveillance of any potential opportunistic infections.
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Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kristin Stendahl
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Abels
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
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Miao J, Krisanapan P, Tangpanithandee S, Thongprayoon C, Mao MA, Cheungpasitporn W. Efficacy of extracorporeal plasma therapy for adult native kidney patients with Primary FSGS: a Systematic review. Ren Fail 2023; 45:2176694. [PMID: 36762994 PMCID: PMC9930861 DOI: 10.1080/0886022x.2023.2176694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
PURPOSE This study aimed to assess efficacy of extracorporeal plasma therapy (EPT), including plasmapheresis (PE), immunoadsorption (IA), low-density lipoprotein apheresis (LDL-A), and lymphocytapheresis (LCAP) for adult native kidney patients with primary focal segmental glomerulosclerosis (FSGS). METHODS A literature search was conducted using MEDLINE, EMBASE and Cochrane Databases through August 2022. Studies that reported outcomes of EPT in adult native kidneys with primary FSGS were enrolled. RESULTS 18 studies with 104 therapy-resistant or refractory primary native FSGS patients were identified. Overall EPT response rate was 56%, with long-term benefit of 46%. Of the 101 non-hemodialysis (HD) patients, 54% achieved remission, with 30% complete remission (CR) and 23% partial remission (PR). Of 31 patients with PE, response rate was 65%; CR and PR rates were 27% and 37% in 30 non-HD patients. Of 61 patients with LDL-A, the response rate was 54%; CR and PR rates were 41% and 3% in 29 non-HD patients. Of 10 patients with IA, response rate was 40%. Of 2 patients with LCAP, 1 achieved CR, and one developed renal failure. All 3 HD patients showed increase in urine output and gradual decrease in urine protein excretion following PE (n = 1) or LDL-A (n = 2). 2 of 3 HD patients ultimately discontinued dialysis. CONCLUSION EPT with immunosuppressive therapy showed benefit in some patients with refractory primary FSGS, and PE appeared to have a higher response rate.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA,CONTACT Jing Miao Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA,Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand,Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Hellman E, Manukyan Z, Mkhitaryan K, Heidarsdottir K, Ragusa MJ, Hartmann J. Large-scale real-world data analysis of source plasma collections using a novel technology-enabled nomogram. Transfusion 2023; 63:2256-2264. [PMID: 37839089 DOI: 10.1111/trf.17579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Source plasma collections are needed to satisfy the growing demand for plasma-derived medicinal products. The US plasma collection target volume has been guided by a standard weight-based FDA-issued nomogram (STAN) since 1992. In this research, large-scale US-based real-world data (RWD) were analyzed to confirm the safety and volume gains of a newly introduced personalized nomogram (PERS) that was previously studied in a premarket randomized controlled environment. STUDY DESIGN AND METHODS A non-inferiority (NI) analysis was conducted to compare the novel nomogram's significant hypotensive adverse event (AE) incidence rate with large historical standard nomogram AE datasets. Additionally, the average target volumes and donor return rates were compared for collections following PERS and STAN. RESULTS A total of 4,816,784 donations (PERS) by 414,957 donors resulted in a rate of 0.0998% (95% CI [0.0970, 0.1027]) significant hypotensive AEs. NI analysis suggested strong non-inferiority of the new technology (Δ = -0.0082%, 95% CI [-0.0113, -0.0050], prespecified NI margin = 0.1080). Average plasma collection target volumes increased by 66.39 mL (8.49%; p < .0001). Consecutive weekly donor return rates were consistent between the two nomograms (PERS: 73.6%, 95% CI [69.6%-76.7%]; STAN: 74.1%, 95% CI [66.1%-77.2%]). DISCUSSION This analysis confirms in a large-scale real-world dataset the key safety parameter and collection benefit of a novel, technology-enabled nomogram. The nomogram may help meet the growing demand for plasma-derived therapies by providing approximately 8.5% more plasma per donation on average while maintaining donor safety and return rates.
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Affiliation(s)
- Eva Hellman
- Global Medical Office, Haemonetics Corporation, Boston, Massachusetts, USA
| | | | | | - Karen Heidarsdottir
- Quality and Postmarket Surveillance, Haemonetics Corporation, Boston, Massachusetts, USA
| | - Michael J Ragusa
- Research and Development, Haemonetics Corporation, Boston, Massachusetts, USA
| | - Jan Hartmann
- Global Medical Office, Haemonetics Corporation, Boston, Massachusetts, USA
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Ferreira AS, Maux Lessa MP, Sanborn K, Kuchibhatla M, Karafin MS, Onwuemene OA. In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III. J Clin Apher 2023; 38:694-702. [PMID: 37548357 PMCID: PMC10841207 DOI: 10.1002/jca.22080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Major bleeding in patients undergoing therapeutic plasma exchange (TPE) has been studied in large databases; but without standardizing bleeding definitions. Therefore, we used standardized definitions to evaluate major bleeding in hospitalized patients undergoing TPE using public use data files from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). STUDY DESIGN AND METHODS In a retrospective cross-sectional analysis, we identified TPE-treated adults in a first inpatient encounter. We evaluated major bleeding prevalence using (1) International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, (2) packed red blood cell (PRBC) transfusion, or (3) hemoglobin (Hgb) decline. Patients with major bleeding prior to their first TPE were excluded from the analysis. RESULTS Among 779 patients undergoing TPE, major bleeding by at least one of the three bleeding definitions occurred in 135 patients (17.3%). For each of the ICD/CPT, PRBC, and Hgb definitions, the prevalence of major bleeding was 2.8% (n = 31), 7.4% (n = 81), and 5.4% (n = 59), respectively. Only 3.7% of bleeds (5/135) were captured by all three definitions and 19.3% (26/135) exclusively by any two pairwise definitions. The addition of PRBC transfusion and Hgb decline to ICD/CPT code definitions increased bleeding prevalence threefold. CONCLUSION Among hospitalized adults undergoing TPE in the REDS-III study, the prevalence of major bleeding was 17.3%. The addition of PRBC and Hgb decline to ICD codes increased bleeding prevalence threefold. Future studies are needed to develop validated models that identify patients at risk for major bleeding during TPE.
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Affiliation(s)
- Alexandre Soares Ferreira
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Kate Sanborn
- Duke Biostatistics, Epidemiology and Research Design Core, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Qureshi ZA, Altaf F, Khanzada M, Thet A, Espinosa L. Ceftriaxone-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Eculizumab: A Rare Case Report. Cureus 2023; 15:e48898. [PMID: 38024015 PMCID: PMC10653270 DOI: 10.7759/cureus.48898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a subtype of thrombotic microangiopathy (TMA) resulting in thrombocytopenia, anemia, fever, renal and neurological deficits. Although many drugs have been associated with drug-induced TTP, ceftriaxone has never been reported. Our case reports a patient who was started on ceftriaxone and developed TTP. Peripheral smear showed schistocytes and thrombocytopenia. Surprisingly, antibody formation against the metalloproteinase (ADAMTS13) levels were low-normal. The patient was treated with plasmapheresis and eczulimab, leading to platelet recovery and symptom resolution. TTP is a rare disorder and can be acquired or idiopathic. TTP can be diagnosed with normal ADAMTS13 as well. Further research is required to assess the mechanism by which ceftriaxone causes TTP. Physicians should consider the possibility of TTP in patients with similar presentations following ceftriaxone therapy and use it for timely diagnosis and treatment. Early diagnosis and treatment of ceftriaxone-induced TTP can prevent devastating consequences.
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Affiliation(s)
- Zaheer A Qureshi
- Internal Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
- Internal Medicine, BronxCare Health System, Bronx, USA
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Aung Thet
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Luis Espinosa
- Internal Medicine, BronxCare Health System, Bronx, USA
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Odish MF, Garimella PS, Crisostomo H, Yi C, Owens RL, Pollema T. Using Cardiohelp, Quadrox, and Nautilus Extracorporeal Membrane Oxygenators as Vascular Access for Hemodialysis, Continuous Renal Replacement Therapy, and Plasmapheresis: A Brief Technical Report. ASAIO J 2023; 69:e455-e459. [PMID: 37399278 PMCID: PMC10602218 DOI: 10.1097/mat.0000000000002005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
The use of intermittent hemodialysis (iHD), and continuous renal replacement therapy (CRRT), along with extracorporeal membrane oxygenation (ECMO) in patients with acute kidney injury (AKI) and end-stage renal disease (ESRD) is very common. In this technical report, we describe the methods to perform these dialytic therapies safely and effectively using the ECMO circuit in lieu of a separate dialysis catheter. Specifically, we describe in detail how to connect these kidney replacement therapy modalities to a Quadrox, Nautilus, and Cardiohelp HLS (combined oxygenator and pump) oxygenator. The dialysis (iHD or CRRT) inlet is attached to the post-oxygenators Luer-Lock, whereas the return is attached to the pre-oxygenator Luer-Lock, both with a dual lumen pigtail. We also discuss the technical aspects of performing plasmapheresis in conjunction with ECMO and iHD or CRRT. Finally, we highlight the fact that the reported technique does not require modifying the ECMO cannulas/tubing which helps maximize safety.
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Affiliation(s)
- Mazen F. Odish
- From the Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, UC San Diego Department of Medicine, La Jolla, California
| | - Pranav S. Garimella
- Division of Nephrology-Hypertension, UC San Diego Department of Medicine, La Jolla, California
| | | | - Cassia Yi
- UC San Diego Health Department of Nursing, La Jolla, California
| | - Robert L. Owens
- From the Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, UC San Diego Department of Medicine, La Jolla, California
| | - Travis Pollema
- Division of Cardiovascular and Thoracic Surgery, UC San Diego Department of Surgery, La Jolla, California
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Tazoe K, Harada N, Takemura K, Nakamae M, Hino M. A Case of IgG1-Lambda Multiple Myeloma With Hyperviscosity Syndrome and Cryoglobulinemia: Identification of the Subclass Fraction by Immunoelectrophoresis and Immunofixation Electrophoresis. Cureus 2023; 15:e48253. [PMID: 38054160 PMCID: PMC10694783 DOI: 10.7759/cureus.48253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 12/07/2023] Open
Abstract
Hyperviscosity syndrome (HVS) is a complication of monoclonal plasma cell tumors. The frequency of HVS depends on the type of monoclonal protein. Immunoglobulin M (IgM) is more closely associated with HVS than IgG, and among IgG subclass monoclonal proteins, IgG3 is most frequently associated with HVS. We herein report a 44-year-old woman with multiple myeloma (MM), HVS, and cryoglobulinemia. Her monoclonal protein and cryoglobulin were IgG1-lambda (λ). She developed HVS at a lower monoclonal protein level because of the properties of the IgG1-derived monoclonal protein and cryoglobulin. Our case highlights the fact that identifying the IgG subclass is useful in predicting the risk of complicating HVS.
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Affiliation(s)
- Kumiyo Tazoe
- Hematology, Osaka Metropolitan University Hospital, Osaka, JPN
| | - Naonori Harada
- Hematology, Osaka Metropolitan University Hospital, Osaka, JPN
- Hematology, Fuchu Hospital, Osaka, JPN
| | - Kazuya Takemura
- Clinical Laboratory, Osaka Metropolitan University Hospital, Osaka, JPN
| | - Mika Nakamae
- Laboratory Medicine and Medical Informatics, Osaka Metropolitan University Hospital, Osaka, JPN
- Clinical Laboratory, Osaka Metropolitan University Hospital, Osaka, JPN
| | - Masayuki Hino
- Hematology, Osaka Metropolitan University Hospital, Osaka, JPN
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Goel A, Zachariah U, Daniel D, Eapen CE. Growing Evidence for Survival Benefit with Plasma Exchange to Treat Liver Failure. J Clin Exp Hepatol 2023; 13:1061-1073. [PMID: 37975044 PMCID: PMC10643514 DOI: 10.1016/j.jceh.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/07/2023] [Indexed: 11/19/2023] Open
Abstract
Plasma exchange (PLEX) to treat liver failure patients is gaining increasing momentum in recent years. Most reports have used PLEX to treat patients with acute liver failure (ALF) or acute on chronic liver failure (ACLF). Etiology of liver disease has an important bearing on the prognosis of the illness in these patients. The accruing data suggest survival benefit with PLEX compared with standard medical treatment to treat ALF and ACLF patients, in randomised controlled trials done world-over. The American College of Apheresis now recommends high-volume PLEX as first-line treatment for ALF patients. Most matched cohort studies done from India which recruited patients with a specific etiology of ALF or ACLF report survival benefit with PLEX compared to standard medical treatment. The survival benefit with PLEX appears more pronounced in ALF patients rather than in ACLF patients. Systematic analysis of the efficacy of PLEX to treat ALF and ACLF patients is needed. There is also a need to identify dynamic predictive scores to assess which patients with ALF or ACLF will respond to PLEX.
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Affiliation(s)
- Ashish Goel
- Departments of Hepatology and Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Uday Zachariah
- Departments of Hepatology and Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Departments of Hepatology and Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Chundamannil E. Eapen
- Departments of Hepatology and Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
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Thomas A, Smithhart C, Chopra M, Jayan A, Ali F, Doughem K, Bhatt A, Scoon J, Larson S. Severe Lupus Enteritis Complicated by Intractable Gastrointestinal Hemorrhage. ACG Case Rep J 2023; 10:e01188. [PMID: 37928230 PMCID: PMC10621909 DOI: 10.14309/crj.0000000000001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023] Open
Abstract
Lupus enteritis (LE) is a rare presentation of systemic lupus erythematosus manifesting with nonspecific symptoms, laboratory derangements, and imaging findings. Rarely, LE may progress to bowel perforation, hemorrhage, and even death. Treatment with systemic glucocorticoids often results in rapid clinical improvement, but patients may require further immunosuppression. We present a case of severe LE complicated by life-threatening intractable gastrointestinal hemorrhage and warm autoimmune hemolytic anemia refractory to glucocorticoids and ultimately requiring massive transfusions, intravenous immunoglobulin, and plasmapheresis. This case illustrates the importance of early specialist involvement and treatment with intravenous immunoglobulin and plasmapheresis for severe, life-threatening LE.
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Affiliation(s)
- Austin Thomas
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Clay Smithhart
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Maneera Chopra
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Athira Jayan
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Faisal Ali
- Division of Gastroenterology, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Karim Doughem
- Division of Rheumatology, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Asmeen Bhatt
- Department of Surgery, Center for Interventional Gastroenterology at UTHealth (iGUT), Houston, TX
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School at UTHealth, Houston, TX
| | - Joanna Scoon
- Division of Critical Care Medicine, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Scott Larson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Bahkali N, Alhawsawi E, Althakafi K, Arab K, Rayes A, Badawi MA. Clinical response to therapeutic plasmapheresis and intravenous immunoglobulin in pregnancies complicated by alloimmunization despite persistently high titers: Report of two cases. Clin Case Rep 2023; 11:e8209. [PMID: 38028069 PMCID: PMC10654475 DOI: 10.1002/ccr3.8209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Plasmapheresis and IVIG use in cases of alloimmunization during pregnancy are effective strategies when severe early fetal anemia is anticipated. Despite no change in antibody titer levels before and after plasmapheresis, clinical response was observed in both fetuses, and both had an excellent obstetrical outcome. Abstract Hemolytic disease of the fetus and newborn is a potentially lethal complication of alloimmunization, and intrauterine fetal blood transfusion (IUBT) is the standard treatment and care plan for severe fetal anemia. However, IUBT is technically unattainable before 20 weeks of gestation. Plasmapheresis and intravenous immunoglobulin (IVIG) are the two treatment modalities described in the literature that postpone the need for transfusion until after 20 weeks. Here, we present two cases of alloimmunization (one with anti-Kell and the other with anti-D). Both had poor outcomes in previous pregnancies because of the early development of severe fetal anemia and hydrops before 24 weeks of gestation. Both patients underwent three sessions of plasmapheresis before 18 weeks, followed by weekly IVIG infusion, which continued until 23-27 weeks of pregnancy. Antibody titers were measured before and after plasmapheresis. In addition, weekly MCA Doppler was performed to monitor the development of severe fetal anemia requiring blood transfusion, which was diagnosed when the peak systolic velocity (PSV) was 1.5 multiples of the median or more. The first patient underwent IUBT at 24 weeks and the second at 28 weeks, as indicated by the MCA Doppler. Both patients were delivered by cesarean section, the first at 34 weeks and the second at 36 weeks, for different obstetrical indications. Both pregnancies resulted in a live birth. We conclude that the use of plasmapheresis and IVIG in alloimmunization during pregnancy is an effective treatment strategy when severe early fetal anemia is anticipated before 20 weeks of gestation. Despite no change in antibody titer levels before and after plasmapheresis, a clinical response was observed in both fetuses, and both had excellent obstetrical outcomes.
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Affiliation(s)
- Nedaa Bahkali
- Department of Obstetrics and Gynecology, Faculty of MedicineKing Abdulaziz UniversityJeddahKingdom of Saudi Arabia
- Department of Obstetrics and GynecologyKing Abdulaziz University HospitalJeddahKingdom of Saudi Arabia
| | - Ebtihal Alhawsawi
- Department of Obstetrics and GynecologyKing Abdulaziz University HospitalJeddahKingdom of Saudi Arabia
| | - Kholoud Althakafi
- Department of Obstetrics and GynecologyKing Abdulaziz Medical CityJeddahKingdom of Saudi Arabia
| | - Kholoud Arab
- Department of Obstetrics and Gynecology, Faculty of MedicineKing Abdulaziz UniversityJeddahKingdom of Saudi Arabia
- Department of Obstetrics and GynecologyKing Abdulaziz University HospitalJeddahKingdom of Saudi Arabia
| | - Almotasimbellah Rayes
- Department of Obstetrics and GynecologyKing Abdulaziz University HospitalJeddahKingdom of Saudi Arabia
| | - Maha A. Badawi
- Department of Hematology, Faculty of MedicineKing Abdulaziz UniversityJeddahKingdom of Saudi Arabia
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Moazezi T, Koh CK. The Use of Plasmapheresis in a Severe Case of Amiodarone-Induced Thyrotoxicosis. JCEM Case Rep 2023; 1:luad123. [PMID: 37942132 PMCID: PMC10629971 DOI: 10.1210/jcemcr/luad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Indexed: 11/10/2023]
Abstract
Amiodarone-induced thyrotoxicosis (AIT) can be difficult to treat since amiodarone's long half-life leads to a persistent effect on thyroid function. We present a case of a 74-year-old male with severe AIT who presented with altered mentation and ultimately required intubation and intensive care for management of thyroid storm. Standard medical therapy for treatment of thyroid storm was initiated immediately, but the patient remained unresponsive with worsening biochemical parameters with increasing total T3 levels and sustained elevated levels of free T4 after 5 days of medical management. Due to the lack of a clinical and biochemical response to conventional medical therapy, the patient was started on plasmapheresis and underwent a total of 7 cycles of plasmapheresis over a period of 10 days. He significantly improved with plasmapheresis and was successfully bridged to a total thyroidectomy, which was completed without complications.
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Affiliation(s)
- Tina Moazezi
- Departments of Internal Medicine and Endocrinology, Advocate Lutheran General Hospital, Park Ridge, IL 60068, USA
| | - Chung-Kay Koh
- Departments of Internal Medicine and Endocrinology, Advocate Lutheran General Hospital, Park Ridge, IL 60068, USA
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Behera TR, Kaur A, Acharya S, Mallick P, Sahu A. Unilateral Diffuse Alveolar Hemorrhage as an Initial Presentation of Microscopic Polyangiitis. Cureus 2023; 15:e46813. [PMID: 37954826 PMCID: PMC10636509 DOI: 10.7759/cureus.46813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition due to widespread damage to small pulmonary vessels commonly caused by systemic vasculitis. Alveolar involvement is typically multi-lobar and bilateral. It frequently presents as bilateral diffuse airspace opacities on chest imaging. Unilateral DAH is rare. Patients presenting with hemoptysis, anemia, hypoxemia, progressive dyspnea, and opacities on chest imaging should be evaluated for systemic vasculitis such as antineutrophilic cytoplasmic antibody (ANCA) vasculitis. We report the case of a 23-year-old female who presented with hemoptysis, severe dyspnea, hypoxemia, anemia, and oliguria. The laboratory exam results showed the patient to be p-ANCA positive, which suggests a diagnosis of microscopic polyangiitis. Chest X-ray showed unilateral airspace opacities, and DAH was confirmed by hemosiderin-laden macrophages on bronchoalveolar fluid histopathological examination. After treatment with plasmapheresis, intravenous methylprednisolone pulse, and cyclophosphamide, the patient's symptoms and radiographic findings improved.
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Affiliation(s)
- Tapas Ranjan Behera
- Nephrology, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
| | | | | | - Prabhat Mallick
- Nephrology, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
| | - Alisha Sahu
- Anesthesiology, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
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48
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Agarwal S, Maheshwari A, Bajpai M. Large volume plasmapheresis using a single-use immunoadsorption column: A cost-effective approach for desensitization in ABO-incompatible liver transplant. J Clin Apher 2023; 38:548-554. [PMID: 37194407 DOI: 10.1002/jca.22058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Liver transplant is a life-saving treatment, but due to the limited availability of suitable liver donors, ABO-incompatible liver transplants (ABOi-LT) are conducted to increase the availability of liver donors. Perioperative desensitization for ABOi-LT is an established strategy to circumvent the risk of graft rejection. A single prolonged session can be performed to achieve the desired titers to avoid using multiple immunoadsorption (IA) columns or off-label reuse of single-use columns. This study retrospectively assessed the effectiveness of a single prolonged plasmapheresis session using IA as a desensitization strategy in live donor liver transplant (LDLT). MATERIALS AND METHODS This retrospective observational study conducted at a center for liver diseases in North India on six ABOi-LDLT patients who underwent single prolonged IA sessions in the perioperative period from January 2018 to June 2021. RESULTS Median baseline titer in patients was 320 (64, 1024). The median plasma volume adsorbed was 7.5 volumes (4, 8) per procedure, with a mean procedure time of 600 min (310-753). The reduction in titer ranged from 4 log to 7 log reduction per procedure. Two patients developed transient hypotension during the procedure, which was managed successfully. The median duration of pre-transplant hospital stay was 1.5 days (1, 3). CONCLUSION Desensitization therapy helps overcome the ABO barrier and decreases the waiting period before a transplant when ABO identical donors are unavailable. A single prolonged IA session reduces the cost of additional IA columns and hospital stay, thus making it a cost-effective approach to desensitization.
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Affiliation(s)
- Sarika Agarwal
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashish Maheshwari
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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Boedecker-Lips S, Judel A, Holtz S, Mayer M, Klimpke P, Kraus D, Schreiner T, Gerstmayer B, Eulitz K, Mayer MC, Weinmann-Menke J. Efficient removal of antibodies to adeno-associated viruses by immunoadsorption. J Clin Apher 2023; 38:590-601. [PMID: 37415533 DOI: 10.1002/jca.22069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Gene therapies based on adeno-associated viruses (AAV) are a therapeutic option to successfully treat monogenetic diseases. However, the influence of pre-existing immunity to AAV can compromise the application of AAV gene therapy, most notably by the presence of neutralizing antibodies (NAb) to AAV. METHODS In the following study, we investigated to what extent the treatment by immunoadsorption (IA) would reduce the levels of human anti-AAV antibodies to AAV2 and AAV5. To that end, we screened blood sera from 40 patients receiving IA treatment because of underlying autoimmune disease or transplant rejection, with detectable AAV-antibodies in 23 patients (22 by NAb detection, and 1 additionally by anti-AAV5 ELISA analysis). RESULTS Our results show that IA efficiently depleted anti-AAV2 NAb with a mean reduction of 3.92 ± 1.09 log2 titer steps (93.4%) after three to five single IA treatments, 45% of seropositive subjects had an anti-AAV2 titer below the threshold titer of 1:5 after the IA treatment series. Anti-AAV5 NAb were reduced to below the threshold titer of 1:5 in all but one of five seropositive subjects. Analysis of total anti-AAV5 antibodies by ELISA demonstrated an anti-AAV5 antibody reduction over the IA treatment series of 2.67 ± 1.16 log2 titer steps (84.3%). CONCLUSION In summary, IA may represent a safe strategy to precondition patients with pre-existing anti-AAV antibodies to make this population eligible for an effective AAV-based gene therapy.
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Affiliation(s)
- Simone Boedecker-Lips
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | - Stefan Holtz
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Magnus Mayer
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Pascal Klimpke
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Kraus
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | | | | | | | - Julia Weinmann-Menke
- Division of Nephrology, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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50
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Hogan KO. Preventative plasmapheresis in a diabetic pregnant patient with hypertriglyceridemia and distal pancreatectomy. Transfus Med 2023; 33:413-415. [PMID: 37562981 DOI: 10.1111/tme.12985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Pregnant patients with a history of hypertriglyceridemia are at increased risk for development of acute pancreatitis. When conservative management fails to maintain triglyceride levels less than 250-500 mg dL-1 , implementation of pregnancy category C medications to prevent pancreatitis must be considered. Plasmapheresis rapidly reduces triglyceride levels and has been reported as a successful third-line therapy for hypertriglyceridemia-induced acute pancreatitis in a limited number of pregnant patients. Use of preventative plasmapheresis as a bridge to delivery is not well characterised. CASE PRESENTATION We report an outpatient plasmapheresis regimen for the control of hypertriglyceridemia in a pregnant patient with a history of diabetes mellitus, hypertriglyceridemia, distal pancreatectomy, and repeat pregnancy loss. During the second trimester, refractory triglyceride levels increased up to 3438 mg dL-1 by 28 weeks gestation. Given the patient's high risk for recurrent pancreatitis and limited remaining pancreatic parenchyma, she was treated acutely with two single-plasma-volume exchanges with 100% albumin over 2 days, decreasing the triglyceride level to 559 mg dL-1 . Subsequent plasmapheresis every 7 to 9 days maintained a triglyceride level of 320-1296 mg dL-1 . The patient experienced no adverse effects and remained outpatient until successful scheduled delivery for hypertension at 33 weeks gestation. DISCUSSION For select patients, early escalation to plasmapheresis may prevent morbidity and mortality associated with acute pancreatitis. An individualised plasmapheresis regimen can serve as a bridge to delivery, which requires close observation and the coordination of a multidisciplinary team.
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Affiliation(s)
- Keenan O Hogan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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