2 | DISCUSSION
TTP is a rare autoimmune disorder that results in small clots forming
throughout the body. A deficiency of the von Willebrand factor
(vWF)-cleaving protease, ADAMTS13 (activity <10%), leads to
very large vWF multimers in the circulation, resulting in microvascular
thrombosis. These microclots can occlude blood vessels, leading to
tissue damage and organ dysfunction due to extensive microangiopathic
hemolytic anemia caused by coagulation cascade activation. Thrombotic
thrombocytopenia-induced myocardial infarction is a rare and potentially
life-threatening condition that can occur as a complication of
thrombotic thrombocytopenic purpura
(TTP)12(). Previous studies have shown
that TTP can also lead to pancreatitis in 1.7% to 2.0% of cases.
Abnormal vWF multimers cause hyaline microthrombi in pancreatic small
vessels, leading to ischemia and inflammatory changes. This case report
describes the occurrence of both acute pancreatitis and myocardial
infarction as potential manifestations of TTP-related microvascular
injury13(). In 2024, Wang et al. reported
a 44-year-old man diagnosed with acute pancreatitis as a rare
manifestation of TTP, who presented with initial symptoms of abdominal
pain14(). Harvey Olsen reported a case
involving a 49-year-old male with TTP-induced acute pancreatitis (AP),
who exhibited symptoms of abdominal pain and bleeding gums. Histological
evaluation of the patient’s pancreatic parenchyma revealed focal
hemorrhages, fat necrosis, and round cell infiltration. Additionally,
the presence of the pancreatic enzyme elastase was noted in the
pancreatic tissue, aligning with the characteristics of
AP10(). A separate review by Antes EH
documented histological alterations in 63 TTP patients with confirmed
AP. Of the nine individuals diagnosed with AP, five exhibited necrosis
and two displayed hemorrhages in the pancreatic tissue, corroborating
the aforementioned mechanism. Furthermore, an animal study demonstrated
that thrombosis in pancreatic veins induced acute necrotizing
hemorrhagic pancreatitis in dogs15().
Swisher et al. detailed the cases of five patients who initially
presented with acute pancreatitis and later exhibited signs of TTP
(including thrombocytopenia, anemia, elevated LDH, and the presence of
schistocytes in blood smears) within a span of one to thirteen
days16().
MI due to TTP is extremely rare as the presenting event of TTP. In 2023,
Mohamed et al. reported a 45-year-old woman who presented with symptoms
of fever, myalgia, diffuse arthralgia, and decreased urination three
days after the diagnosis of Non-ST-Segment Elevation Myocardial
Infarction and undergoing percutaneous coronary intervention (PCI).
Attention to laboratory tests and a low ADAMTS13 level with a high
inhibitory titer led to the diagnosis of
TTP11(). Also, in 2022, Geeth et al.
reported a 68-year-old woman who presented with an initial complaint of
chest pain along with mental changes and fatigue, and a platelet count
of 30,000/uL, with a non-ST elevation myocardial infarction as an
unusual presentation of TTP. She was treated with plasmapheresis and
steroids17(). Șalaru et
al.18(), Ghodsi et
al.19(), Takimoto et
al.20(), and Dahal et
al.21() also reported myocardial
infarction as a rare and early manifestation of TTP. In this report, at
the same time as the diagnosis of TTP and AP for the patient,
Non-ST-Segment Elevation Myocardial Infarction was also discussed.
Cardiac complications caused by TTP have a high mortality rate, and
early diagnosis and management of this disease are very
important11(). Studies have shown that
TTP patients with high levels of positive cardiac biomarkers are at
higher risk for severe complications and mortality. Troponin levels
greater than 0.25 ng/mL are associated with a threefold increased risk
of mortality in TTP patients22(). In this
report, the troponin level was first 410 ng/mL and then 1100 ng/mL.
Management of myocardial infarction in TTP patients can be challenging
due to low platelet counts. Standard recommendations suggest a cardiac
workup with clinical examination, Electrocardiogram(EKG),
echocardiography, and serum evaluation of cardiac enzymes. In TTP
patients with myocardial damage, immediate plasmapheresis is necessary
to prevent further cardiac damage and mortality. Additionally, due to
the increased risk of fatal arrhythmia, continuous heart monitoring is
necessary for these patients11(). Here we
report a 43-year-old man with acute pancreatitis and myocardial
infarction (MI) as potential manifestations of TTP-related microvascular
injury. This case report describes the occurrence of both acute
pancreatitis and myocardial infarction as complications of TTP,
emphasizing the critical importance of early diagnosis and intervention
in the management of this disorder. It also provides insight into the
challenges of diagnosing and treating TTP with unusual presentations
such as pancreatitis and myocardial infarction. The complexity of
managing TTP, especially when it is associated with multiorgan
involvement, underscores the need for physicians to be vigilant in
caring for such complications.