Platelet transfusion in thrombotic thrombocytopenic purpura: between Scylla and Charybdis

Platelet (PLT) transfusion in patients with thrombotic thrombocytopenic purpura (TTP) is usually considered to be contraindicated based on reports of clinical deterioration and death after PLT transfusion, generally before plasma exchange (PE) was started. The rationale is that the increased number of circulating PLTs after transfusion aggravates microvascular thrombosis. Notwithstanding, some communications suggest that, under an established regimen of PE, TTP patients could receive PLT transfusions, if required, without clinical consequence. We report the case of a 45-year-old woman diagnosed with TTP after a 10-day history of asthenia, malaise, and fever. PE was prescribed, but because she had no available peripheral access, a central venous catheter was required. Her PLT count was 6 × 10 per L. Insertion of a 9F, doublelumen catheter was attempted in the femoral vein in the operating room by an experienced anesthesiologist. The maneuver was unsuccessful bilaterally, and a hematoma formed in the right groin despite local pressure. A leukoreduced five buffy coat–derived PLT concentrate (PC) in additive solution, containing 5.3 × 10 PLTs, was transfused. Ten minutes after the PC was administered, the PLT count was 86 × 10 per L. The corrected count increment was 23,446. At that time, a double-lumen catheter was placed successfully in a jugular vein without complication. No adverse changes were observed in her clinical status. Before PE was initiated 10 hours later, a 13 percent decrease in her hematocrit (Hct) was noted, probably due to groin bleeding. Treatment was started with steroids and daily PEs of 110 percent of plasma volume with a cell separator (COBE Spectra, Gambro BCT, Lakewood, CO). Cryosupernatant plasma was used as the replacement solution. There was progressive normalization of previously altered laboratory values (PLT count, haptoglobin, lactate dehydrogenase, Hct, and creatinine) and clinical improvement. The right groin hematoma was resorbed without sequelae. The patient was discharged after 20 PEs. She is currently well 20 months after completing treatment. Bleeding related to central venous catheter insertion is a major cause of morbidity and mortality in TTP. In our own experience, one patient died after inserting a jugular catheter (1 of 40 TTP patients treated in our institution). We are not recommending liberal PLT transfusions to patients with TTP. Rather, we suggest that the risk of bleeding should be considered carefully when a central catheter needs to be inserted in a TTP patient before PE. Usually, we try to avoid falling under the six heads of Scylla (PLT transfusion) at the risk of plunging into the whirlpool Charybdis (bleeding complications). In the Odyssey, Odysseus chose to lose some of his crew to the monster Scylla, rather than his whole ship to Charybdis. The challenge we face is even harder, that is, transfusing PCs to TTP patients to protect them from potentially dangerous bleeding without precipitating a fatal event. This objective may be achievable if PE is performed promptly after PLT transfusion. Miguel Lozano, MD, PhD e-mail: mlozano@clinic.ub. es Abel Domingo, MD Arturo Pereira, MD, PhD Department of Hemotherapy and Hemostasis Jaime Fontanals, MD, PhD Department of Anesthesiology Roberto Mazzara, MD, PhD Department of Hemotherapy and Hemostasis Agustí Pi i Sunyer Biomedical Research Institute (IDIBAPS) Hôpital Clínic of Barcelona University of Barcelona. Villarroel 170 08036 Barcelona, Spain