Ebru Çakir EDİS, Özlem YILDIZ, Muzaffer DEMİR, Tuncay ÇAĞLAR

İMMUN TROMBOSİTOPENİK PURPURADA İVİG SONRASI PULMONER TROMBOEMBOLİ GELİŞEN OLGUDA TROMBOLİTİK TEDAVİ KULLANIMI

İmmun trombositopenik purpura (İTP), glikoprotein IIb/IIIa'ya karşı gelişen antikorla kaplı trombositlerin retikülo-endotelyal sistemde yıkımı ile karakterize otoimmun bir hastalıktır. İntraven öz immunglobulin (İVİG); yaşamı tehlikeye sokan kanamalı kronik İTP'de, etkin ve güvenli bir tedavi yöntemi olarak bilinmesine rağmen literatürde tedavi sonrası tromboz gelişen olgular bildirilmektedir. Kronik İTP tanısı ile takipli, bir ay önce İVİG uygulanmış 62 yaşında kadın hasta, alt extremitede şişlik ve nefes darlığı ile başvurdu. Alt ekstremite doppler ultrasonografisinde sol popliteal-femoral vende trombüs ve toraks tomografisinde bilateral pulmoner arterlerde trombüs izlendi. Hemodinamisi bozulan hastaya trombolitik tedavi yapma kararı verildi ancak trombositopenisi (38.000/mm3) mevcuttu. Trombosit transf üzyonu ile beraber rekombinan doku plazminojen aktivatör (t-PA 100mg) uygulandı. Komplikasyon gelişmeyen hastada tromboz etiyolojisine yönelik yapılan edinsel ve kalıtsal testlerde bir patoloji saptanmadı. Yalnızca etiyolojik ajan olarak İVİG kullanımı vardı. Olgumuz; İTP'da İVİG tedavisi ve tromboz birlikteliğine dikkat çekmek, yaşamı tehdit eden masif pulmoner tromboemboli durumunda kanama diyatezi açısından gerekli destek tedavi yapılarak trombolitik tedavi uygulanabilece ğini vurgulamak amacıyla literatür bilgileri eşli- ğinde sunulmuştur.

Anahtar Kelimeler:

İmmun trombositopenik purpura, intravenöz immunglobulin, pulmoner emboli, trombolitik tedavi

THROMBOLYTIC TREATMENT IN A CASE OF PULMONARY THROMBOEMBOLISM SUBSEQUENT TO IVIG THERAPY FOR IMMUNE THROMBOCYTOPENIC PURPURA

Immune thrombocytopenic purpura (ITP) is an otoimmune disease, characterised by the demolition of trombocytes coated with antibodies against glicoprotein IIb/IIIa. Intravenous immunoglobulin (IVIG), is known to be an effective and reliable therapy in cases of life endangering, bleeding, chronic ITP, however here are few cases of thrombosis reported in literature after use of this therapy approach. 62 year old female patient, with a history of chronic ITP and IVIG treatment a month ago, presented with swelling in lower extremities and difficulty in breathing. Doppler ultrasonography of lower extremities showed thrombus in left popliteal femoral vein and thorax tomography revealed several thrombuses in bilateral pulmonary arteries. Thrombolytıc therapy is planned to the patient with hemodynamic instabiliy but the patient had thrombocytopenia (38.000/mm3). Trombocyte transfusion combined with tissue plasminogen activator (t-PA) was chosen as the therapy approach. No complication occurred and no pathology showed at acquired and genetic test results. Etiologic agent was only IVIG treatment. Our case is presented along with medical literature to take attention at the association of IVIG therapy for ITP and thrombosis occurrence and to highlight the use of support therapy with thrombolytic agents in such cases.

Keywords:

Immune thrombocytopenic purpura, ıntravenous ımmunoglobuline, pulmonary embolism, thrombolytıc therapy,

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1. BC Douglas, Blanchette VS. Immune Thrombocytopenic Purpura. N Engl J Med 2002; 346: 995-1008.
2. Lee YJ, Shin JU, Lee J, Kim K, Kim WS, Ahn JS, Jung CW, Kang WK. A case of deep vein thrombosis and pulmonary thromboembolism after intravenous immunoglobulin therapy. J Korean Med 2007; 22: 758-61.
3. Negi VS, Elluru S, Siberil S, Graff-Dubois S, Mouthon L, Kazatchkine MD, Lacroix-Desmazes S, Bayry J, Kaveri SV. Intravenous immunoglobulin: an update on the clinical use and mechanisms of action. J Clin Immunol 2007; 27: 233-45.
4. Imbach P, Barandun S, d’Apuzzo V, Baumgartner C, Hirt A, Morell A, Rossi E, Schoni M, Vest M, Wagner HP. High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura in childhood. Lancet 1981; 1: 1228-31.
5. Anderson D, Ali K, Blanchette V, Brouwers M, Couban S, Radmoor P, Huebsch L, Hume H, McLeod A, Meyer R, Moltzan C, Nahirniak S, Nantel S, Pineo G, Rock G. Guidelines on the use of intravenous immunoglobulin for hematologic conditions. Transfus Med Rev. 2007; 21: 9-56.
6. Katz U, Achiron A, Sherer Y, Shoenfeld Y. Safety ofintravenous immunoglobulin (IVIG) therapy. Autoimmun Rev. 2007; 6(4): 257-9.
7. L. Ross Pierce, Nisha J. Risks associated with intravenous immunoglobulin. Transfus Med Rev 2003; 17: 241-51.
8. Hamrock DJ. Adverse events associated with intravenous immunoglobulin therapy. Int Immunopharmacol 2006; 6: 535-42.
9. Woodruff RK, Grigg AP, Firkin FC, Smith IL. Fatal thrombotic events during treatment of autoimmunne thrombocytopenia with intravenous immunoglobulin in elderly patients. Lancet 1986; 2: 217-8.
10. Paran D, Herishanu Y, Elkayam O, Shopin L, Ben-Ami R. Venous and arterial thrombosis following administration of intravenous immunoglobulins. Blood Coagul Fibrinolysis 2005; 16: 313-8.
11. Elkayam O, Paran D, Milo R, Davidovitz Y, Almoznino-Sarafian D, Zelltser D, Yaron M, Caspi D. Acute myocardial infarction associated with high dose intravenous immunoglobulin infusion for autoimmune disorders. A study of four cases. Ann Rheum Dis 2000; 59: 77-80.
12. Emerson GG, Herndon CN, Sreih AG. Thrombotic complications after intravenous immunoglobulin therapy in two patients. Pharmacotherapy 2002; 22: 1638-41.
13. Dalakas MC. High dose intravenous immunoglobulin and serum viscosity: risk of precipitating thromboembolic events. Neurology 1994; 44: 223-6.
14. Hefer D, Jaloudi M. Thromboembolic events as an emerging adverse effect during high dose intravenous immunoglobulin therapy in elderly patients: a case report and discussion of the relevant literature. Ann Hematol 2004; 83: 661-5.
15. Alexandrescu DT, Dutcher JP, Hughes Jt, Kaplan J, Wiernik PH. Strokes after intravenous gama globulin: thrombotic phenomenon in patients with risk factors or just coincidence? Am J Hematol 2005; 78: 216-20.
16. Sorensen R. Expert opinion regarding clinical and other outcome considerations in the formulary review of immune globulin. J Manag Care Pharm 2007; 13: 278-83.