Microangiopathic hemolytic anemia/Acquired Thrombotic Thrombocytopenic Purpura as a first presentation of pancreatic cancer


Microangiopathic hemolytic anemia/Acquired Thrombotic Thrombocytopenic Purpura as a first presentation of pancreatic cancer


Meshaal Alanzi1, Khalid E. Ahmed1, Bassel Dakkak1, Mhd Baraa Habib1, Ahmed O. Saleh2, Mohamed A. Yassin3, Shehab F. Mohamed3

1.Department of Internal Medicine, Hamad medical corporation, Doha, Qatar;2.Department of Endocrinology, Hamad medical corporation, Doha, Qatar; 3.Department of Hematology, National center for cancer care and research, Hamad medical corporation, Doha, Qatar.


International-Journal-of-Case-Reports-2d code

Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening hematologic disorder. It is mainly characterized by thrombocytopenia, microangiopathic hemolytic anemia (MAHA), fever, renal impairment and neurological abnormality. Plasmapheresis and steroids are the standard of care.

MAHA/TTP can be the initial presentation of solid organ malignancies especially gastrointestinal tumors. We report a 56-year-old female patient who presented with progressive back pain, tiredness, easy bruising, fever and weight loss. Laboratory results showed anemia, thrombocytopenia, and schistocytes in the peripheral smear. An initial diagnosis of thrombotic thrombocytopenic purpura (TTP) was made on the basis of clinical presentation and lab findings. She was treated with corticosteroids and plasma exchange but with no major response.

CT abdomen and PET CT were suggestive of pancreatic carcinoma with extensive lymph nodal, organs and bone metastases. Supraclavicular lymph node biopsy was compatible with metastatic adenocarcinoma. As a result, the diagnosis of pancreatic cancer was established and the decision was for palliative treatment.

This case highlights the need to consider malignancy in patients with MAHA/TTP especially if it does not respond to plasmapheresis. Hence, the treatment of MAHA/TTP could be directed to the underlying malignancy if available.


Keywords: TTP, pancreatic cancer, plasmapheresis


Free Full-text PDF


How to cite this article:

Meshaal Alanzi, Khalid E. Ahmed, Bassel Dakkak, Mhd Baraa Habib, Ahmed O. Saleh, Mohamed A. Yassin, Shehab F. Mohamed. Microangiopathic hemolytic anemia/Acquired Thrombotic Thrombocytopenic Purpura as a first presentation of pancreatic cancer . International Journal of Case Reports, 2020 4:143. DOI: 10.28933/ijcr-2020-06-1605


References:

1. Lechner K, Obermeier HL. Cancer-related microangiopathic hemolytic anemia: clinical and laboratory features in 168 reported cases. Medicine (Baltimore). 2012;91(4):195‐205. doi:10.1097/MD.0b013e3182603598 https://pubmed.ncbi.nlm.nih.gov/22732949/
2. Kremer Hovinga JA, Coppo P, Lämmle B, Moake JL, Miyata T, Vanhoorelbeke K. Thrombotic thrombocytopenic purpura. Nat Rev Dis Primers. 2017;3:17020. Published 2017 Apr 6. doi:10.1038/nrdp.2017.20 https://www.ncbi.nlm.nih.gov/pubmed/28382967/
3. Page EE, Kremer Hovinga JA, Terrell DR, Vesely SK, George JN. Thrombotic thrombocytopenic purpura: diagnostic criteria, clinical features, and long-term outcomes from 1995 through 2015. Blood Adv. 2017;1(10):590‐600. Published 2017 Apr 6. doi:10.1182/bloodadvances.2017005124 https://www.ncbi.nlm.nih.gov/pubmed?term=29296701
4. https://ouhsc.edu/platelets/TTP/frequency%20of%20ttp%20hus.html
5. Tsai HM. Thrombotic thrombocytopenic purpura: a thrombotic disorder caused by ADAMTS13 deficiency. Hematol Oncol Clin North Am. 2007;21(4):609‐v. doi:10.1016/j.hoc.2007.06.003 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001253/
6. Govind Babu K, Bhat GR. Cancer-associated thrombotic microangiopathy. Ecancermedicalscience. 2016;10:649. Published 2016 Jun 28. doi:10.3332/ecancer.2016.649 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929977/
7. George JN. Systemic malignancies as a cause of unexpected microangiopathic hemolytic anemia and thrombocytopenia. Oncology (Williston Park). 2011;25(10):908‐914. https://pubmed.ncbi.nlm.nih.gov/22010388/
8. Francis KK, Kalyanam N, Terrell DR, Vesely SK, George JN. Disseminated malignancy misdiagnosed as thrombotic thrombocytopenic purpura: A report of 10 patients and a systematic review of published cases. Oncologist. 2007;12(1):11‐19. doi:10.1634/theoncologist.12-1-11 https://www.ncbi.nlm.nih.gov/pubmed/17227897
9. Wolff D, Brinkmann B, Emmrich J, Steiner M. Metastatic pancreatic carcinoma presenting as thrombotic thrombocytopenic purpura. Pancreas. 2003;26(3):314. doi:10.1097/00006676-200304000-00021 https://www.ncbi.nlm.nih.gov/pubmed/12657963
10. Susano R, Caminal L, Ferro J, Rubiales A, de Le-ra J, de Quirós JF. Anemia hemolítica microangiopática asociada a neoplasias: análisis de cinco casos y revisión de la literatura [Microangiopathic hemolytic anemia associated with neoplasms: an analysis of 5 cases and a review of the literature]. Rev Clin Esp. 1994;194(8):603‐606. https://www.ncbi.nlm.nih.gov/pubmed/7938839