Thrombotic thrombocytopenic purpura and cardiac papillary fibroelastoma: A 'unique coexistence'

Praveen Ramakrishnan Geethakumari, Alexander Rubin, Gabor Varadi

Research output: Contribution to journalArticle

Abstract

Thrombotic thrombocytopenic purpura (TTP), a complex thrombotic microangiopathy, remains an evolving enigma. A 49-year-old African-American woman presented with acute left hemiplegia, an ischemic cerebrovascular accident involving the right middle cerebral artery. Sequential appearance of thrombocytopenia and evidence of microangiopathic haemolysis led to the diagnosis of acquired idiopathic autoimmune TTP. This was managed with plasma exchange (PEX) and steroids. Early haematologic relapse within a month was managed with the addition of rituximab attaining sustained remission. The patient presented 3 years later with acute confusion and expressive aphasia due to multiple infarcts involving the left parieto-occipital cortex. Transoesophageal echocardiography demonstrated a pedunculated 6mm mitral valvular mass consistent with a papillary fibroelastoma. Anticoagulation was instituted and the patient was continued on therapeutic oral warfarin. A haematologic relapse of TTP eventually emerged and was managed with PEX, steroids and rituximab. This vignette demonstrates several dilemmas in the clinical presentation, diagnosis and management of TTP in current day practice. Rituximab has adjuvant benefits to PEX and is being investigated as potential first-line therapy. Monitoring ADAMTS13 activity and inhibitor titre, as in our case, prove to have prognostic significance. Cardiac fibroelastomas are rare benign cardiac tumours usually arising from valvular endocardium with thromboembolic potential. One of the proposed mechanisms of origin of these masses is organizing thrombi in the setting of endocardial injury and inflammation questioning a possible link to thrombotic microangiopathy. To the best of our knowledge, this is the first report of this unique coexistence.

Original languageEnglish (US)
Pages (from-to)881-883
Number of pages3
JournalBlood Coagulation and Fibrinolysis
Volume24
Issue number8
DOIs
StatePublished - Dec 1 2013

Fingerprint

Thrombotic Thrombocytopenic Purpura
Plasma Exchange
Thrombotic Microangiopathies
Steroids
Broca Aphasia
Recurrence
Endocardium
Occipital Lobe
Heart Neoplasms
Hemiplegia
Idiopathic Thrombocytopenic Purpura
Transesophageal Echocardiography
Middle Cerebral Artery
Warfarin
Hemolysis
Thrombocytopenia
African Americans
Thrombosis
Stroke
Inflammation

Keywords

  • ADAMTS13
  • ischemic stroke
  • papillary fibroelastoma
  • plasma exchange
  • thrombotic microangiopathy
  • thrombotic thrombocytopenic purpura

ASJC Scopus subject areas

  • Hematology

Cite this

Thrombotic thrombocytopenic purpura and cardiac papillary fibroelastoma : A 'unique coexistence'. / Ramakrishnan Geethakumari, Praveen; Rubin, Alexander; Varadi, Gabor.

In: Blood Coagulation and Fibrinolysis, Vol. 24, No. 8, 01.12.2013, p. 881-883.

Research output: Contribution to journalArticle

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