Megan Buchholz presentation: case study

TTP Case Study 41 year old woman PMHx : Chronic Anemia, Rheumatoid Arthritis, UGIB (Upper Gastric Intestinal bleed) March 20th, 2012 presented to her GP with abdominal pain. CBC showed plt count of 17, Hg 101 Urine dip positive for blood and protein Started on Cipro for dx of UTI Sent home

2 days later she returns to her GP The next day she goes to the ER Worsening pain and general malaise Abx changed, Tylenol #3 added The next day she goes to the ER Presented with c/o of feeling very unwell Plts 12 S/B Haeme – dx ITP Started on Prednisone 1mg/kg/day with f/u in 1 week

The next day her son brings her back to the ER She is very confused In ER has seizure, followed by decreased LOC She is intubated, medicated and transferred to their ICU. Hg 72 and plts 12, moderate fragments on film. Transferred to SMH ICU with Dx of TTP (March 25, 2012)

Course of treatment as St. Michael’s Plts 6, LDH 1189, Hg 100, Cr 118, on admission Started on Plasmapheresis 1.0 PV that day, Prednisone 1mg/kg started Exchanged with CSP. Treatment #8 c/o ‘itchiness’. Tx’d with 50 mg Benadryl IV. Experienced Hematological deterioration. ↓plts, ↑LDH, Code blue, seized – transferred to ICU Changed daily PLEX to 1.5 PV, Given Rituximab x 4 Had 19 treatments in total Plts 213, LDH 135, Hg 123, Cr 46, on discharge

Refractory Relapse 2 months later (June 21, 2012) Again started with 1.0 PV exchange with CSP During Treatment #9 (as an out pt) Pt c/o feeling ‘itchy’. Whole body hives noted. 50 mg Benadryl IV Pt then c/o ‘feeling on fire’. Hydrocortisone 100 mg IV given. PLEX stopped, rinse-back started. Then c/o difficulty breathing. O2 4L NP applied. O2 sat 85%, BP 67/36 NS 700 cc given via bolus Face started to swell, 0.25 mg Epinephrine IM given BP ↑ 110/72, transferred to Emergency Department Monitored x 24 and sent home. Discontinued PLEX Plts 258, LDH 142, Hg 108, Cr 52 Total number of treatments 9

Refractory Relapse 2 weeks later (July 13th, 2012) Presented in follow up clinic Plts 14, LDH 360, Hg 128, Cr 48 Re-initiated Plasmapheresis at 1.0 PV Exchanged with SDP Better after 8 treatments. Zero allergic reactions Plts 173, LDH 185, Hg 108, Cr 55 on discharge No relapses since