Severe Thrombotic Microangiopathy Associated with Brucellosis: Successful Treatment with Plasmapheresis

Abstract

Brucellosis is a disease that may lead to changes in hematologic parameters such as anemia, neutropenia, and thrombocytopenia; however, thrombotic microangiopathy (TMA) is a rare finding. Severe TMA may be associated with life-threatening hematologic, renal, and neurologic disorders. To prevent this mortality caused by brucellosis, prompt recognition of this complication and prompt therapy are essential. A patient with TMA associated with Brucella melitensis is presented who initially presented with fever, skin purpura, epistaxis, confusion, microangiopathic hemolytic anemia, and thrombocytopenia. TMA was treated with plasmapheresis with cryosupernatant plasma replacement, energetically. A rapid improvement in platelet count, lactate dehydrogenase level, hemolytic anemia, and neurologic symptoms was observed with this treatment. For cases with infection-induced thrombotic microangiopathy, short-term plasmapheresis may be applied as an urgent therapy in addition to antimicrobial therapy.

Keywords

Brucellosis Thrombotic microangiopathy Plasmapheresis

References

Al-Eissa Y , Al-Zamil F , Al-Mugeiren M , et al. Childhood brucellosis: A deceptive infectious disease. Scand J Infect Dis 1999;123:129.

Kern WF . The thrombotic microangiopathies: Thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. PDQ Hematology. London: BC Decker, 2002, pp. 210-219.

Burns ER , Lee V , Rubinstein A. Treatment of septic thrombocytopenia with immune globulin. J Clin Immunol 1991;11:363.

Levine SH . Miscellaneous causes of thrombocytopenia. In: Richard L , Foerster J , Lukens J , Paraskevas F , Green JP , Rodgers GM , eds. Wintrobe’s Clinical Hematology, vol. 2, Baltimore: Williams and Wilkins, 1999.

Kelton JG , Neame PB , Gauldie J , et al. Elevated platelet associated IgG in the thrombocytopenia of septicemia. N Engl J Med 1979;300:760.

Lopez D , Nieto ML , Fernandez-Gallardo S , et al. Occupancy of platelet receptors for platelet-activating factor in patients with septicemia. J Clin Invest 1989;883:1733.

Karmali MA , Petric M , Lim C , et al. The association between idiopathic hemolytic uremic syndrome and infection by verotoxin-producing Escherichia coli. J Infect Dis 1985;151:777.

Koster F , Levin J , Walker L , et al. Hemolytic-uraemic syndrome after shigellosis. N Engl J Med 1978;298:927.

Martinez J. Microangiopathic hemolytic anemia. In: Beutler E , Lichtman MA , Coller BS , Kippd TJ , Seligsohn U , eds. Williams Hematology; 6th ed. New York: McGraw-Hill, 2001, p. 623.

10.

Baker NM , Mills AE , Rachman I , et al. Hemolytic-uraemic syndrome in typhoid fever. Br Med J 1974;2:84.

11.

Salata RA . Brucellosis. In: Bennet and Plum , eds. Cecil Textbook of Medicine, 20th ed. Philadelphia: WB Saunders, 1996, p. 1678.

12.

Al-Eissa YA , Kambal AM , Al-Nasser MN , et al. Childhood brucellosis: A study of 102 cases. Pediatr Infect Dis J 1990;9:74.

13.

Aysha MH , Shayip MA . Pancytopenia and other haematological findings in brucellosis. Scand J Haematol 1986;36:335.

14.

Crosby E , Llosa L , Quesada MM , et al. Hematologic changes in brucellosis. J Infect Dis 1984;150:419.

15.

Lynch EC , McKechnie JC , Alfrey CP . Brucellosis with pancytopenia. Ann Intern Med 1968;69:319.

16.

Zuazu JP , Duran JW , Julia AF . Hemophagocytosis in brucellosis. N Engl J Med 1979;301:1185.

17.

Gurkan E , Baslamisli F , Guvenc B , et al. Immune thrombocytopenic purpura associated withBrucella and Toxoplasma infections. Am J Hematol 2003;74(1):52.

18.

Pisoni R , Remuzzi G. Thrombotic microangiopathy. Eur J Intern Med 2000;11(3):135.

19.

Di Mario A , Sica S , Zini G , et al. Microangiopathic hemolytic anemia and severe thrombocytopenia in Brucellainfection. Ann Hematol 1995;70(1):59.

20.

Yaramis A , Kervancioglu M , Yildirim I , et al. Severe microangiopathic hemolytic anemia and thrombocytopenia in a child withBrucella infection. Ann Hematol 2001;80:546.