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.