An Interesting Case of Refractory Thrombotic Thrombocytopenic Purpura in the First Trimester of a Twin Pregnancy.

Thrombotic thrombocytopenic purpura (TTP) is a rare pregnancy complication characterized by microangiopathic hemolytic anemia and consumption thrombocytopenia. We herein describe the case report of a 32-year-old woman who was six weeks pregnant with twins and developed thrombotic thrombocytic purpura (TTP). The patient had a history of sickle cell trait, migraines, and preeclampsia. She presented with complaints of nausea, fatigue, sore throat, and cough and was found to be anemic with a hemoglobin of 7 g/dl and thrombocytopenic with a platelet count of 8 x 103/µL. The patient was promptly initiated on steroids and plasmapheresis with an excellent initial response. However, after three days, she developed a sudden onset headache and shortness of breath, and repeat labs showed worsening anemia (7.3 g/dl) and thrombocytopenia (8 x 103/µL). ADAMTS13 activity was significantly low at 2%. Plasmapheresis was continued, and caplacizumab and rituximab treatment was initiated. The fetal ultrasound showed no cardiac activity in the fetal poles, and the patient had a dilation and curettage (D&C) for a missed abortion. She was discharged with a prednisone taper, daily caplacizumab, and weekly rituximab. This case report underscores the criticality of the prompt identification of TTP in its early stages, and appropriate management strategies for patients with refractory TTP (rTTP), including plasmapheresis, caplacizumab, and rituximab.

Long-Term Results of Phototherapeutic Keratectomy Versus Mechanical Epithelial Removal Followed by Corneal Collagen Cross-Linking for Keratoconus.

PURPOSE: To compare the long-term visual outcomes of patients with keratoconus treated with either phototherapeutic keratectomy (PTK) or mechanical epithelial removal before corneal collagen cross-linking (CXL) at 1, 3, 6, and 12 months postoperatively. METHODS: CXL was performed by 1 of 3 surgeons (K.B., W.B.J., or G.M.). Seventeen eyes underwent mechanical epithelial removal before CXL and were consecutively selected after being matched with the 17 eyes in the PTK group for the variables of procedure date, average keratometry, and pachymetry. All cones were central. Manifest refraction spherical equivalent, sphere, cylinder, corrected distance visual acuity (CDVA), and pachymetry were measured and compared preoperatively and in follow-up. RESULTS: The mean CDVA change in the PTK group at 12 months postoperatively was statistically different from the mean CDVA change in the mechanical group at 12 months postoperatively (P = 0.031). The PTK group had significantly better outcomes in visual acuity 12 months postoperatively than did the mechanical group (P > 0.05). The mean number of lines of improvement in the PTK and mechanical groups were 2.30 ± 0.96 and 0.00 ± 0.33 lines, respectively (P = 0.0036). The mean change between the preoperative and 12 months postoperative manifest refraction spherical equivalent for the PTK and mechanical groups were 0.78 ± 0.65 and 0.17 ± 0.65, respectively (P > 0.05). CONCLUSIONS: PTK CXL resulted in better visual outcomes in comparison with mechanical epithelial removal CXL 1 year after treatment.

Rare appendicitis-like syndrome: the case of the obstructing broccoli.

The diagnosis of acute appendicitis can be somewhat obscure in a patient that presents with right lower quadrant abdominal pain. The advancement and ease of imaging have made CT scanning readily available in the emergency department. Management can be challenging when the patient has a high likelihood of appendicitis based on clinical suspicion and negative CT scan. The purpose of this case report is to demonstrate how an obstructing bezoar caused an appendicitis-like syndrome in a patient with negative CT scan and clinical diagnosis of acute appendicitis. This case report will discuss the appendicitis-like syndrome of an obstructing bezoar and an approach at management.