A case of thrombotic thrombocytopenic purpura and pancreatitis as a result of milk-alkali syndrome
Crit Care Med
Learning Objectives: The initiating factor of thrombotic thrombocytopenic purpura (TTP) is only recognized in few published cases. Known causes of TTP include pregnancy, autoimmune disorders, vasculitides, malignancy, and medications. We describe an interesting case of milk-alkali syndrome and pancreatitis as the cause of TTP. Methods: A 27-year-old woman with a history of papillary thyroid carcinoma presented with abdominal pain, nausea, and vomiting. She had been taking up to 46 calcium carbonate supplements for symptoms of perioral numbness and fatigue which she attributed to hypocalcemia. On presentation, she was found to have a calcium of 22.8, severe pancreatitis, and acute kidney injury which improved with medical management. Two days after admission, she developed a fever and had a substantial drop in hemoglobin and platelets. She was found to have hemolytic anemia with marked schistocytes on peripheral smear. She was therefore treated for TTP with five sessions of plasma exchange until schistocytes were minimal. ADAMTS13 activity was normal. Results: There is a known relationship between pancreatitis and TTP however is not well defined. The most likely explanation is that the release of inflammatory cytokines from pancreatitis stimulates the release of vWF multimers from the endothelium which increases platelet adhesion, and therefore the resultant thrombogenesis causes TTP. An association between hypercalcemia and pancreatitis is known, and it has been suggested that it is caused by deposition of calcium in the pancreatic duct and calcium activation of trypsinogen within the pancreatic parenchyma. Increased levels of cytokines and microvascular damage due to elevated pancreatic enzymes and systemic inflammatory response syndrome result in the formation of microthrombi. In addition to causing TTP, this can aggravate the acute pancreatitis as well. There have been few case reports suggesting an association between pancreatitis and TTP, however the role between milk alkali syndrome as a cause of pancreatitis preceding TTP has not been discovered. Our case suggests that an association may be inherent and warrants further discussion and investigation.