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. 2020 Mar 19:15:204-210.
doi: 10.1515/med-2020-0030. eCollection 2020.

Streptococcus Pneumoniae-associated Thrombotic Microangiopathy in an Immunosuppressed Adult

Yumi Ichikawa  1 , Masato Murata  1   2 , Makoto Aoki  1   2 , Jun Nakajima  1   2 , Yuta Isshiki  1   2 , Yusuke Sawada  1   2 , Kazunori Fukushima  1   2 , Kiyohiro Oshima  1   2
Affiliations

Streptococcus Pneumoniae-associated Thrombotic Microangiopathy in an Immunosuppressed Adult

Yumi Ichikawa et al. Open Med (Wars). .

Abstract

A 62-year-old male who was receiving prednisolone and methotrexate for scleroderma and rheumatoid arthritis complained of diarrhea and vomiting, and was transferred to our hospital for detailed examination and treatment of renal dysfunction and thrombocytopenia. Hemolytic anemia and crushed erythrocytes were found during the patient's course; therefore, we suspected thrombotic microangiopathy (TMA). His ADAMTS13 activity was 60.3% and his ADAMTS13 inhibitor was under 0.5. In addition, his blood culture was positive for Streptococcus pneumoniae, and we finally diagnosed Streptococcus pneumoniae-associated TMA (pTMA). The patient was treated with antibiotics and hemodialysis. The patient recovered and was discharged on the 45th hospital day. Adult pTMA cases are remarkably rare. We herein report a successfully treated adult case of pTMA.

Keywords: Antibiotics; Hemolytic uremic syndrome; Infection; Plasma exchange.

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Conflict of interest statement

Conflict of interest Conflict of interest statement: Authors state no conflict of interest

Figures

Figure 1
Figure 1
(a) Chest roentgenogram on arrival at our hospital showed no abnormal findings. (b) Chest computed tomography (CT) on arrival showed no abnormal findings. (c) Abdominal CT on arrival showed no abnormal findings. (d) Abdominal CT on arrival showed neither splenomegaly nor atrophy of the spleen.
Figure 2
Figure 2
Our patient’s clinical course. Crushed erythrocytes were found in the peripheral blood smear performed at the previons hospital, on the 5th hospital day. ABPC: ampicillin; CHDF: continuous hemodiafiltration; Cr: creatinine; Hb: hemoglobin; HD: hemodialysis; MEPM: meropenem; PC: platelet concentrate; Plt: platelet count; PE: plasma exchange.
Figure 3
Figure 3
Crushed erythrocytes (arrow) in a peripheral blood smear stained with May-Giemsa stain (x1000).
Figure 4
Figure 4
Comparison of the classification of TMAs. In the classification of JSN/JPS, a genetic or complement abnormality can be found and the differentiation between atypical hemolytic uremic syndrome (aHUS) and secondary TMAs is sometimes difficult. Patients with true aHUS (i.e., complement-mediated aHUS) are sometimes diagnosed as having secondary TMA. In the classification of KDIGO, the differentiation between primary aHUS and other aHUSs, such as pregnancy, transplant are sometimes difficult. Patients with primary aHUS are sometimes diagnosed as having another type of aHUS [4]. JSN/JPS, Japanese Society of Nephrology and the Japan Pediatric Society; TMA, Thrombotic microangiopathy; aHUS, atypical hemolytic uremic syndrome; HUS, hemolytic uremic syndrome; TTP, thrombotic thrombocytopenic purpura; KDIGO, Kidney Disease Improving Global Outcomes.
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