Clearance of severely elevated plasma free hemoglobin with total plasma exchange in a pediatric ECMO patient

Extracorporeal membrane oxygenation (ECMO)-related hemolysis is common with reported incidence of 5%–18%. Plasma free hemoglobin (PFH) levels are used as a marker for hemolysis and elevated PFH is associated with acute kidney injury (AKI). Limited literature exists regarding treatment of severe hemolysis and clearance of PFH. We report 8-year-old male child on VA ECMO with severe hemolysis (PFH 895 mg/dL) and worsening AKI showing significant improvement in PFH after single volume exchange plasmapheresis with Fresh Frozen Plasma (FFP) performed in tandem via ECMO circuit.

Sepsis Mimicking TTP-Case Report and Review of Literature

Here we report a case of Sepsis mimicking as thrombotic thrombocytopenic purpura in a cancer patient with Urothelioma. A 61-year-old man with High grade Urothelial Carcinoma of left renal pelvis (Multifocal disease) Stage-4 presented with Fever on and off since 1 week and shortness of breath at rest since 2 days and hematuria since 1 day.Later in the course, he developed thrombocytopenia followed by MAHA (Micro Angiopathic haemolytic Anaemia), and other lab abnormalities .Thrombotic thrombocytopenic purpura (TTP) was suspected, and total plasma exchange was considered. Since serum procalcitonin,Total leucocyte count was very high and also had elevated prothrombin time, ADAMTS13(a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13) was sent for confirmation showed that ADAMTS13 activity of more than 10% for which plasmapheresis was delayed , later patient was treated for sepsis , but patient did not respond and succumbed . This case shows that Sepsis can mimic TTP making diagnosis and treatment extremely difficult. In this type of clinical dilemma to do total plasma exchange (TPE) which is the main modality of treatment for TTP ADAMTS13 activity helps us to prioritise treatment

Plasmapheresis for the Treatment of Acute Pancreatitis due to Severe Hypertriglyceridemia

Severe hypertriglyceridemia (HTG) is associated with acute pancreatitis (AP). Treatment options include total plasma exchange (TPE). We report a case of AP due to severe HTG treated with TPE.

Toxic Epidermal Necrolysis Therapy with TPE and IVIG—10 Years of Experience of the Burns Treatment Center

Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens–Johnson’s Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

Total Plasma Exchange in Hypertriglyceridemia-Induced Pancreatitis: Case Report and Literature Review

Objective. To emphasize the role of apheresis in management of pancreatitis. Methods. The clinical course of a patient admitted for hypertriglyceridemia-induced pancreatitis (HTGP) complicated by multiorgan dysfunction is described, who demonstrated dramatic improvement in his clinical status after total plasma exchange (TPE). In addition, the current guidelines for TPE and the alternative treatment options for HTGP are also presented. Results. A patient presenting with pancreatitis associated with severe systemic inflammatory response was admitted to our hospital with an initial triglyceride level of 1181 mg/dL. Given the patient’s worsening clinical condition, he was started on TPE with a rapid fall in his serum TG levels, in turn leading to early clinical recovery. Conclusion. Though various therapeutic options for the treatment of HTGP are described in literature, there are no set guidelines available to tackle this difficult clinical situation. TPE, albeit not very well known in this context, is one of the many therapies available. Though it leads to a rapid, precipitous fall in the TG levels and early symptom resolution, the data about the long-term morbidity as well as the effectiveness of this therapy is still lacking.

Purtscher-like retinopathy in a 56-year-old Thai female with anti-glomerular basement membrane glomerulonephritis

A 56-year-old Thai female was referred to Naresuan university hospital with anemia and pitting edema both legs. She had underlying diseases of hypertension, hypercholesterolemia and chronic renal failure with anemia. Before her referral, she was treated by an internist at a provincial hospital. With deterioration of creatinine level and anemic symptom, she was advised to see a nephrologist for the diagnosis of causative pathology and treatment. The reevaluation of chronic renal failure was done. The results of laboratory investigation were creatinine level of 2.42 mg/dl, blood urea nitrogen (BUN) 44 mg/dl and the urinalysis found microscopic hematuria. Further evaluations for hematuria ; vaginoscopy, cystoscopy and ultrasonography of genitourinary system, were performed consequently but all investigations were unremarkable. Then, renal biopsy was done with the result of anti-glomerular basement membrane glomerulonephritis. The hemodialysis and total plasma exchange were done several times to reduce the antibody of anti glomerular basement membrane level.During her admission, she complained of sudden blurred vision both eyes after the ninth total plasma exchange. She has no previous ocular problems nor physical trauma. The ocular examination showed visual acuity of counting fingers both eyes. Anterior segment was unremarkable for her age. The posterior segments showed retinal thickening around the posterior poles with clear intervening zones both eyes with some intraretinal hemorrhage which was compatible with Purtscher-like retinopathy by clinical. The pathogenesis of Purtscher-like retinopathy was investigated with negative results. The counseling was done and the treatment of observation was chosen by the patient and her family. Then she was discharged and followed up at out patient unit of ophthalmology department, Naresuan university hospital. Conclusion: The Purtscher-like retinopathy is a rare ocular disease with variable treatment strategies and outcomes. In complicated case without obvious causes, the pathogenesis of the disease should be investigated which directed to the proper treatment and better visual outcome.