plasmapheresis J Matthew Rhinewalt MD PGY4 Internal MedicinePediatrics University of MS Medical Center Jackson MS Introduction Vitamin B12 deficiency Multiorgan dysfunction Variety of clinical presentations ID: 669490
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Slide1
Why did vitamin B12 deficiency respond to plasmapheresis?
J. Matthew
Rhinewalt
, MD, PGY-4
Internal Medicine/Pediatrics
University of MS Medical Center
Jackson, MSSlide2
IntroductionVitamin B12 deficiency:Multi-organ dysfunctionVariety of clinical presentationsMay present clinically similar to thrombotic thrombocytopenic purpura (TTP)Slide3
Case Description – History62 y/o manCC: confusionHPI: 3 days of confusion per emergency medical personnelpt unable to answer any questions upon presentation and no family present
PMH: type 2 diabetes, seizure disorder, alcoholism, illicit drug useSlide4
Case Description – Physical ExamPertinent Physical ExamTemperature 100.5°FWeight 185lbsSleepy/confusedJugular venous pressure 10cm
Liver edge 3cm below right costal margin
No evidence of bleeding or petechiae
Negative bedside fecal occult blood testingSlide5
Case Description - LabsPertinent (+) labs:WBC 3.3
Hgb
5
Hct
15%
MCV 108
Plt
58,000
Retic
count 0.9%
(corrected)
LDH >2500
haptoglobin
<10
total bilirubin 2.5 (indirect 1.7)
Creatinine 1.6
(baseline 0.8)
(b
aseline
0.7)Slide6
Case Description - LabsPertinent (-/nrl) labs:
Glucose
Urine drug screen
Alcohol level
Creatine kinase
Troponin
Ammonia
Fecal occult blood testing
Prothrombin timeSlide7
Case Description - LabsBlood Smear:Hypersegmented neutrophilsRare schistocytesMany tear drop cells
Moll. NEJM. 1996; 335:323. August 1, 1996
.Slide8
ProblemsFeverHemolytic/Macrocytic AnemiaLow Reticulocyte CountThrombocytopeniaAltered Mental Status
Acute Kidney Injury
History of Alcoholism, Type 2 Diabetes, Seizure DisorderSlide9
Initial Differential Diagnosis#1 - Thrombotic Thrombocytopenic Purpura#2 - Vitamin B12 Deficiency#3 - Leukemia / Bone Marrow MalignancySlide10
ManagementHematology consultPlasmapheresis for possible TTP while awaiting labsSlide11
Therapy4 units PRBC transfusion: hospital day 1Plasmapheresis: hospital day 1-3(12 bags FFP each treatment)Slide12
ResultsClinical improvement after first plasmapheresis:hemolysismental statusrenal function
ADMIT
HOSP DAY
2
LDH
>2500
979
Haptoglobin
<10
15
Bilirubin
3.4
2.6
Creatinine
1.6
0.98Slide13
Interesting ResultsAdamTS13 activity normalFolate RBC level normalLeukemia/lymphoma panel normal
Vitamin B12 level 30pg/mL
(resulted on hospital day 3)
Slide14
Continued ManagementOn hospital day 3: Vitamin B12 1000mcg IM dailySlide15
Upon Discharge (Hospital Day 8)PE: mental status back to baselineLabs:Creatinine back to baseline
Hgb 10
Platelet count 124,000
Reticulocyte count 13%
(corrected)
LDH 777Slide16
Why did he rapidly improve with plasmapheresis?Slide17
How much vitamin B12 is in FFP?Unable to locate a referenceIs it degraded during processing?Slide18
Thank you to Dr. AsfourUMMC blood bank pathologistRandom sampling of 4 bags of FFP for B12 levelsResults: 300 – 500
pg/mL
Our patient’s level was 30 pg/mL
How much vitamin B12 is in FFP?Slide19
Clinical ImpactVitamin B12 levels in FFP were comparable to serum levels of non-deficient patientsneed for baseline B12 levelsigns & symptoms of vitamin B12 deficiency may likely improve if given FFPSlide20
Thank You Mohamed A. Asfour, MDTaylor Pruett, MDJohn C. Henegan, MD