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Thrombotic thrombocytopenic purpura
}} Thrombotic thrombocytopenic purpura (TTP or Moschcowitz disease) is a raredisorder of the blood coagulationsystem that in most cases arises from the deficiency or inhibition of the enzymeADAMTS13, which is responsible for cleaving large multimers of von Willebrand factor. It is a serious condition that leads to hemolysisand end-organ damage, and may require plasmapheresistherapy.
Signs and symptomsClassically, the following five symptoms are indicative of this elusive disease:
DiagnosisThe combination of the symptoms and a routine blood film often lead to the detection of schistocytes (fragmented red cells) and "helmet cells" on the blood film. This is indicative of breakdown of red blood cellsthrough factors in the small blood vessels. Other tests to be performed are reticulocytecounts, lactate dehydrogenase, direct antiglobulin test(DAT/Coombs' test), renal function(creatinine), electrolytesand liver enzymes. Very high LDHlevels may be present; these mainly originate from the poorly perfused tissues, and not so much from the hemolysis. The above symptoms and findings are the main criteria for diagnosis, although the fever, renal and neurological symptoms can be absent. Increased lactate dehydrogenaselevels and a negative direct antiglobulin test(DAT, Coombs' test) in the context of microangiopathic haemolytic anaemia (MAHA) are indicative of TTP. The main differential diagnosisis between TTP and hemolytic uremic syndrome(HUS). The syndromes show a remarkable overlap in symptoms, and researchers have argued in the past that the two diseases are part of a continuum. Generally, HUS leads mainly to renalsymptoms, while neurological abnormalities tend to be rare in HUS. Also, many HUS cases are preceded by an episode of bloody diarrheadue to infection with a verotoxin-positive E. coli O157:H7(enterohemorrhagic strain). Although its utility in clinical settings is still under discussion, measurement of the von Willebrand factor-cleaving metalloproteinaseADAMTS13(see below) and IgGinhibitors to this enzyme have been shown to aid in the diagnosis of TTP. In the series reported by Zheng et al (2004), low ADAMTS13 activity and detection of an inhibitor predicted response to therapy, and high titres of the inhibitor predicted the necessity of additional therapy. The inhibitor is measured by inactivating innate ADAMTS13 in the patient's plasma by heating it, and then diluting it (1:1, 1:2, 1:4 etc) in saline by titration. These dilutions are then mixed with normal plasma. If ADAMTS13 activity can be detected in all dilutions, then no inhibitor is detectable. If decreased activity is limited to low dilutions, there are low inhibitor concentrations (low titers), while decreased activity in all or most dilutions shows high inhibitor levels. CausesTTP (as with other MAHAs) is caused by spontaneous aggregationof plateletsand activation of coagulationin the small blood vessels. Platelets are consumed in the coagulation process, and the fibrinmesh quite literally "tears apart" red blood cells, leading to hemolysis. Roughly, there are two forms of TTP: idiopathic and secondary TTP. A special case is the inherited deficiency of ADAMTS13, known as the Upshaw-Shulman syndrome. Idiopathic TTPThe idiopathic (literally: of unknown cause) form of TTP was recently linked to the inhibition of the enzymeADAMTS13 by antibodies, rendering TTP an autoimmune disease. ADAMTS13 is a metalloproteinaseresponsible for the breakdown of the so-called von Willebrand factor(vWF), a protein that links platelets, blood clots, and the blood vessel wall in the process of blood coagulation. Very large vWF molecules are more prone to lead to coagulation. Hence, without proper cleavage of vWF by ADAMTS13, coagulation occurs at a higher rate, especially in the part of the blood vessel system where vWF is most active due to high shear stress: in the microvasculature. In idiopathic TTP, severely decreased (<5% of normal) ADAMTS13 activity can be detected in most (80%) patients, and inhibitors are often found in this subgroup (44-56%). Secondary TTPSecondary TTP is diagnosed when the patient's history mentions one of the known features associated with TTP. It comprises about 40% of all cases of TTP. Predisposing factors are:
The mechanism of secondary TTP is poorly understood, as ADAMTS13 activity is generally not as depressed as in idiopathic TTP, and inihibitors cannot be detected. Upshaw-Shulman syndromeA hereditary form of TTP is called the Upshaw-Shulman syndrome; this is generally due to inherited deficiency of ADAMTS13 (frameshift and point mutations). Patients with this inherited ADAMTS13 deficiency have a surprisingly mild phenotype, but develop TTP in clinical situations with increased von Willebrand factorlevels, e.g. infection. Reportedly, 5-10% of all TTP cases are due to Upshaw-Shulman syndrome. TreatmentSince the early 1990s, plasmapheresishas become the treatment of choice for TTP. This is the removal of the patient's blood plasmathrough apheresisand replacement with donor's plasma (fresh frozen plasmaor cryosupernatant); the procedure has to be repeated daily to eliminate the inhibitor and ablate the symptoms. Lactate dehydrogenaselevels are generally used to monitor disease activity. Many TTP patients need additional immunosuppressivetherapy, with steroids(prednisone), vincristine, cyclophosphamide, splenectomyor a combination of the above. Rituximab, a monoclonal antibodytargeting B cells, has been successfully been used to treat patients with refractory disease. Children with Upshaw-Shulman syndrome receive plasma every three weeks prophylactically; this maintains adequate levels of functioning ADAMTS13. EpidemiologyThe incidence of TTP is about 3-6 per million people per year. As with most other autoimmune disorders, idiopathic TTP occurs more often in women and blacks, while the secondary forms do not show this distribution. PrognosisThe mortality rate is approximately 95% for untreated cases, but the prognosis is reasonably favorable (80-90%) for patients with idiopathic TTP diagnosed and treated early with plasmapheresis. Approximately one-third of patients experiencing a TTP episode have a relapse within 10 years following their first attack. Secondary TTP still has an dismal prognosis, with mortality rates despite treatment being reported as 59% to 100%. HistoryTTP was initially described in a 16-year old girl by a Dr Eli Moschcowitz of New York Cityin 1924. Moschcowitz ascribed the disease (incorrectly) to a toxic cause. References
External links
fr:Purpura thrombotique thrombocytopénique Categories: Autoimmune diseases| Hematology| Rare diseases
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