Mann, Shivtaj, DO

Mcenroe, Damon, MD

Vadhar, Sagar, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineBetween A Rock and A Hard Place: ThromboticThrombocytopenic Purpura Induced ST-ElevationMyocardial InfarctionSagar Vadhar DOLehigh Valley Health Network, Sagar.Vadhar@lvhn.orgDamon Mcenroe MDLehigh Valley Health Network, Damon.Mcenroe@lvhn.orgShivtaj Mann DOLehigh Valley Health Network, shivtaj.mann@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/medicinePart of the Internal Medicine CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtVadhar, S. McEnroe, D. Mann, S. (2018, November 10). Between A Rock and A Hard Place: Thrombotic Thrombocytopenic PurpuraInduced ST-Elevation Myocardial Infarction. Poster Presented at: The American College of Physicians (APC), Scranton, PA.© 2018 Lehigh Valley Health NetworkBetween A Rock and A Hard Place: Thrombotic Thrombocytopenic Purpura Induced ST-Elevation Myocardial InfarctionSagar R. Vadhar, DO, Damon McEnroe, MD, Shivtaj S. Mann, DODepartment of Internal Medicine, Lehigh Valley Health Network, Allentown, PennsylvaniaBACKGROUND•  Thrombotic Thrombocytopenic Purpura (TTP) is a rare and life-threatening coagulation disorder caused by antibodies against ADAMTS13.  Loss of ADAMTS13 activity can lead to organ ischemia and thrombi formation secondary to depletion of hemostatic factors. It is reported that approximately 15-41% of TTP cases are complicated with a myocardial infarction (MI). CASE PRESENTATION•  A 57-year-old female presented to the ER with complaints of hematuria and abdominal pain.•  Labs demonstrated Hgb 8.0 g/dL, Platelets 9.0 thou/cmm, LDH 9342 u/L, Direct bilirubin 2.0 mg/dL (Total bilirubin 6.6 mg/dL), INR 1.9,  SCr 2.46 mg/dL (baseline <1.0 mg/dL), and Troponin 8.41 ng/L.•  Peripheral smear demonstrated schistocytes.•  The patient was clinically diagnosed with TTP. INTERVENTIONS•  The patient was administered FFP and  started on plasmapheresis to reduce antibody mediated destruction of ADAMTS13. RESULTS•  ADAMTS13 activity was obtained which resulted at 2.0% (normal >66%).•  Unfortunately, the patient went into PEA arrest with EKG revealing STEMI in leads 2,3, avF and V1-V2. Catheterization (PCI) was deemed too high risk for bleeding and renal failure considering the patient’s AKI and thrombocytopenia. Resuscitative measures were stopped after 5 rounds of CPR.DISCUSSION•  MI is a well described complication of TTP; however, subsequent management remains controversial.•  Recently, studies have shown a potential role for corticosteroids and Rituxan in order reduce thrombi formation; neither of which were used in our patient. •  This presentation illustrates the importance of acknowledging MI as a common complication of TTP and brings to attention the role of immunosuppressive agents as possible therapies in cases where PCI is contraindicated.REFERENCESFigure 1: Courtesy of Dr. Erhabor OsaroFigure 2: Courtesy of CMC EKG Masters - https://www.cmcecg.comFigure 3 and 4: Blood 2017 130:1181-1188; doi: https://doi.org/10.1182/blood-2017-04-636431Figure 4: Therapies targeting the pathophysiology of TTPFigure 1: Peripheral smear demonstrating schistocytes in TTP.Figure 2: EKG demonstrating acute ST elevations in inferior leads (II, III, avF) and anterior leads (V1, V2).Figure 3: a. Physiology of ADAMTS13 and b. Pathology of ADAMTS13 in TTP.

Between A Rock and A Hard Place: Thrombotic Thrombocytopenic Purpura Induced ST-Elevation Myocardial Infarction

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Between A Rock and A Hard Place: Thrombotic Thrombocytopenic Purpura Induced ST-Elevation Myocardial Infarction

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