Abstract: PUB055
A Case Imitating Thrombotic Microangiopathy
Session Information
Category: Acute Kidney Injury
- 103 AKI: Mechanisms
Authors
- Jafari, Golriz, UCLA-Olive View Medical Center, Los Angeles, California, United States
- Pham, Phuong-Chi T., UCLA-Olive View Medical Center, Los Angeles, California, United States
- Konanur venkataram, Raghu, Olive View- UCLA Medical Center, Porter Ranch, California, United States
- Nguyen, Thuan Vinh, UCLA-Olive View Nephrology, North Hills, California, United States
- Kamarzarian, Anita, UCLA -Olive View Medical Center, La Canada, California, United States
Introduction
The combined finding of hemolytic anemia, thrombocytopenia and organ injury, in particular AKI, are the hallmark signs of thrombotic microangiopathies (TMA). The differential is broad, presentations are diverse and most cases severe and life threatening. Risks associated with therapy must be calculated accordingly.
Case Description
A 44 year old female presented with fatigue and body aches 1 week after a motor vehicle accident. Hemoglobin 7.6 g/dl and platelets 16K. Prior to accident she had left knee pain, nausea, poor oral intake and weight loss for 2-3 weeks. No major trauma or injuries resulting from the accident. Only past medical history was a neck plaque like rash 9 months prior that was treated with antibiotics. Later she reported dysuria, fever and chills. Social history positive for prior cocaine use and current marijuana.
Initially afebrile, then developed a temp 37.9 BP 115/92 HR 108. Exam was notable for suprapubic/costovertebral tenderness, left knee erythema, warmth and pain and a macular erythematous rash.
WBC 6.4K, BUN 107 mg/dl Cr 4.59 mg/dl Albumin 1.6 g/dl UA: 182 WBC 112 RBC, Urine Protein/Cr ratio 3.7 gm
Blood cultures and Urine cultures positive for E coli. Orthopedic evaluation ruled out septic joint. She was treated with antibiotics, fluids and platelet transfusion. Central venous catheter was placed for plasmapheresis. Blood smear revealed that schistocytes present, however haptoglobin values were high and bilirubin was normal. Therefore patient was managed medically and plasmapheresis was not implemented. Cr gradually improved to 1.82 mg/dl, on day 4 platelets>50K. ADAMTS13 levels were within normal range and serologies were negative: ANA, ANCA, HBV, HCV, HIV.
Discussion
The differential for the presentation of thrombocytopenia, hemolytic anemia and organ dysfunction is broad including TMAs such as TTP, HUS (shiga toxin or complement mediated) but also include other etiologies that augment complement activation such as sepsis, auto-immune disorders, malignancy, malignant hypertension and pregnancy. Treatment options such as plasmapheresis for TTP or complement cycle immune modulators such as eculizumab for aHUS are available however risks must be calculated based on clinical judgement. In this case the findings were due to E. Coli sepsis due to pyelonephritis rather than TTP or HUS and patient improved with sepsis treatment.