RFX4 is an intrinsic factor for neuronal differentiation through induction of proneural genes POU3F2 and NEUROD1.

Proneural genes play a crucial role in neuronal differentiation. However, our understanding of the regulatory mechanisms governing proneural genes during neuronal differentiation remains limited. RFX4, identified as a candidate regulator of proneural genes, has been reported to be associated with the development of neuropsychiatric disorders. To uncover the regulatory relationship, we utilized a combination of multi-omics data, including ATAC-seq, ChIP-seq, Hi-C, and RNA-seq, to identify RFX4 as an upstream regulator of proneural genes. We further validated the role of RFX4 using an in vitro model of neuronal differentiation with RFX4 knock-in and a CRISPR-Cas9 knock-out system. As a result, we found that RFX4 directly interacts with the promoters of POU3F2 and NEUROD1. Transcriptomic analysis revealed a set of genes associated with neuronal development, which are highly implicated in the development of neuropsychiatric disorders, including schizophrenia. Notably, ectopic expression of RFX4 can drive human embryonic stem cells toward a neuronal fate. Our results strongly indicate that RFX4 serves as a direct upstream regulator of proneural genes, a role that is essential for normal neuronal development. Impairments in RFX4 function could potentially be related to the development of various neuropsychiatric disorders. However, understanding the precise mechanisms by which the RFX4 gene influences the onset of neuropsychiatric disorders requires further investigation through human genetic studies.

Activation of neurotoxic A1-reactive astrocytes by SFTS virus infection accelerates fatal brain damage in IFNAR1-/- mice.

Severe fever with thrombocytopenia syndrome (SFTS) has a high mortality rate compared to other infectious diseases. SFTS is particularly associated with a high risk of mortality in immunocompromised individuals, while most patients who die of SFTS exhibit symptoms of severe encephalitis before death. However, the region of brain damage and mechanisms by which the SFTS virus (SFTSV) causes encephalitis remains unknown. Here, we revealed that SFTSV infects the brainstem and spinal cord, which are regions of the brain associated with respiratory function, and motor nerves in IFNAR1-/- mice. Further, we show that A1-reactive astrocytes are activated, causing nerve cell death, in infected mice. Primary astrocytes of SFTSV-infected IFNAR1-/- mice also induced neuronal cell death through the activation of A1-reactive astrocytes. Herein, we showed that SFTSV induces fatal neuroinflammation in the brain regions important for respiratory function and motor nerve, which may underlie mortality in SFTS patients. This study provides new insights for the treatment of SFTS, for which there is currently no therapeutic approach.

Real-world outcomes of third-line immune checkpoint inhibitors versus irinotecan-based chemotherapy in patients with advanced gastric cancer: a Korean, multicenter study (KCSG ST22-06).

BACKGROUND: Immune checkpoint inhibitor (ICI) or irinotecan-based chemotherapy is frequently used after failure of second-line paclitaxel plus ramucirumab treatment for patients with locally advanced unresectable or metastatic advanced gastric cancer (AGC). This study aimed to compare the efficacy between ICI and irinotecan-based chemotherapy as third-line treatment in patients with AGC. METHODS: We retrospectively reviewed patients with AGC, whose third-line treatment started between July 2019 and June 2021 at 17 institutions in Korea. The ICI group included patients who received nivolumab or pembrolizumab, and the irinotecan-based chemotherapy group included patients who received irinotecan or FOLFIRI (5-fluorouracil, leucovorin and irinotecan). RESULTS: A total of 363 patients [n = 129 (ICI) and n = 234 (irinotecan-based chemotherapy)] were analyzed. The median progression-free survival was 2.3 and 2.9 months in ICI and irinotecan-based chemotherapy groups, respectively (p = 0.802). The median overall survival (OS) was 5.5 and 6.0 months in ICI and irinotecan-based chemotherapy groups, respectively (p = 0.786). For all patients included in this study, multivariable analysis showed that weight loss, peritoneal metastasis, low serum sodium or albumin, and short duration of second-line treatment were associated with inferior OS (p < 0.05). ICI showed significantly longer OS than irinotecan-based chemotherapy in patients without peritoneal metastasis. Whereas ICI showed significantly shorter OS in patients without PD-L1 expression than irinotecan-based chemotherapy. CONCLUSIONS: No significant difference in survival outcome was observed between ICI and irinotecan-based chemotherapy as third-line treatment for AGC patients. ICI might be preferred for patients without peritoneal metastasis and irinotecan-based chemotherapy for patients with tumors without PD-L1 expression. TRIAL REGISTRATION: This study was registered in the Clinical Trial Registry of Korea ( https://cris.nih.go.kr : KCT 0007732).

Melatonin alleviates myocardial dysfunction through inhibition of endothelial-to-mesenchymal transition via the NF-κB pathway.

Endothelial-to-mesenchymal transition (EndMT) is a complex biological process of cellular transdifferentiation by which endothelial cells (ECs) lose their characteristics and acquire mesenchymal properties, leading to cardiovascular remodeling and complications in the adult cardiovascular diseases environment. Melatonin is involved in numerous physiological and pathological processes, including aging, and has anti-inflammatory and antioxidant activities. This molecule is an effective therapeutic candidate for preventing oxidative stress, regulating endothelial function, and maintaining the EndMT balance to provide cardiovascular protection. Although recent studies have documented improved cardiac function by melatonin, the mechanism of action of melatonin on EndMT remains unclear. The present study investigated the effects of melatonin on induced EndMT by transforming growth factor-ß2/interleukin-1ß in both in vivo and in vitro models. The results revealed that melatonin reduced the migratory ability and reactive oxygen species levels of the cells and ameliorated mitochondrial dysfunction in vitro. Our findings indicate that melatonin prevents endothelial dysfunction and inhibits EndMT by activating related pathways, including nuclear factor kappa B and Smad. We also demonstrated that this molecule plays a crucial role in restoring cardiac function by regulating the EndMT process in the ischemic myocardial condition, both in vessel organoids and myocardial infarction (MI) animal models. In conclusion, melatonin is a promising agent that attenuates EC dysfunction and ameliorates cardiac damage compromising the EndMT process after MI.

The Importance of Confirming False Homozygosity in Pretransplant HLA Typing Results of Patients with Hematologic Malignancies.

Loss of heterozygosity (LOH) on chromosome 6p, where the HLA genes are located, can result in incorrect homozygosity findings during HLA genotyping in patients with hematologic malignancies. The degree of HLA compatibility between donor and recipient is crucial in hematopoietic stem cell transplantation. Therefore, we present a case of false homozygosity in HLA genotyping due to LOH on chromosome 6p in a patient diagnosed with acute myeloid leukemia (AML). HLA molecular typing was conducted on both peripheral blood and buccal swab samples. The analysis included sequence-based typing (SBT) and next-generation sequencing-based typing. Additionally, chromosomal microarray analysis (CMA) was performed. A 68-year-old male presented with anemia and thrombocytopenia. Subsequent bone marrow examination confirmed AML. High-resolution HLA genotyping of Peripheral blood during blast crisis revealed homozygosity at the -A, -B, and -C loci. Conventional karyotyping showed a normal karyotype, 46,XY[20]. Retesting of HLA genotyping one week later confirmed the homozygous results. Subsequently, HLA typing was repeated using buccal swab specimens, confirming heterozygosity at all 4 HLA loci. CMA on peripheral blood samples during blast crisis revealed a large terminal region of copy-neutral LOH spanning approximately 43.5 Mb in the chromosome region 6p25.3p21.1. LOH at the HLA gene locus can significantly impact donor selection, potentially leading to the selection of mistakenly identified homozygous donors. Clinicians and laboratory personnel should be aware of these issues to prevent erroneous HLA typing results in patients with hematologic malignancies. It is advisable to confirm the HLA typing of recipients with hematologic malignancies whenever homozygosity is detected at any locus. This can be achieved through careful interpretation of low peaks in SBT, and by using buccal swab samples or peripheral blood collected after achieving remission.

First Case of Septic Shock Caused by Cetobacterium Somerae.

BACKGROUND: Cetobacterium somerae rarely causes infection in humans. Most studies on C. somerae have analyzed its role in the intestinal system of freshwater fish. METHODS: Herein, we report a case of septic shock caused by C. somerae in an elderly patient. RESULTS: Blood culture revealed growth of a gram-negative, rod-shaped anaerobic bacterium, which was identified as C. somerae through MALDI-TOF analyses. Although C. somerae is a resident species in the gut, it can cause systemic infection, which can be fatal. CONCLUSIONS: When C. somerae is identified, consideration should be given to the possibility of the infection originating from the intestinal tract.

Photobiomodulation with near-infrared laser for tinnitus management: preliminary animal experiments and randomized clinical trials.

This study investigates the effectiveness of photobiomodulation therapy (PBMT) in treating chronic high-frequency tinnitus with the TINI device, a near-infrared (830 nm) laser. The study includes preliminary animal experiments with 28 mice and a randomized controlled trial with 56 participants to examine the functional and molecular changes in the auditory system that PBMT may cause. The animal model used sodium salicylate to induce tinnitus, followed by PBMT, which showed promising reductions in the behavioral evidence of tinnitus and a reversal of tinnitus-associated upregulation of vesicular glutamate transporters 2 expression in the ipsilateral dorsal cochlear nucleus (p < 0.05). In the clinical trial, participants with chronic high-frequency tinnitus received trans-tympanic application of the TINI device. The results did not show a significant difference in tinnitus score at the final time point when compared to the sham group. However, questionnaires revealed significant improvements in tinnitus symptoms and psychological outcomes following treatment with the TINI device compared to before treatment (p < 0.05). These findings suggest that while PBMT has potential benefits, its clinical effectiveness may be unclear due to its complex nature and interaction with other conditions. Further research is required to optimize treatment parameters and gain a complete understanding of the therapeutic potential of PBMT in managing tinnitus.

Nanoplasmonic microarray-based solid-phase amplification for highly sensitive and multiplexed molecular diagnostics: application for detecting SARS-CoV-2.

A novel approach is introduced using nanoplasmonic microarray-based solid-phase recombinase polymerase amplification (RPA) that offers high sensitivity and multiplexing capabilities for gene detection. Nanoplasmonic microarrays were developed through one-step immobilization of streptavidin/biotin primers and fine-tuning the amplicon size to achieve high plasmon-enhanced fluorescence (PEF) on the nanoplasmonic substrate, thereby improving sensitivity. The specificity and sensitivity of solid-phase RPA on nanoplasmonic microarrays was evaluated in detecting E, N, and RdRP genes of SARS-CoV-2. High specificity was achieved by minimizing primer-dimer formation and employing a stringent washing process and high sensitivity obtained with a limit of detection of four copies per reaction within 30 min. In clinical testing with nasopharyngeal swab samples (n = 30), the nanoplasmonic microarrays demonstrated a 100% consistency with the PCR results for detecting SARS-CoV-2, including differentiation of Omicron mutations BA.1 and BA.2. This approach overcomes the sensitivity issue of solid-phase amplification, as well as offers rapidity, high multiplexing capabilities, and simplified equipment by using isothermal reaction, making it a valuable tool for on-site molecular diagnostics.

Inhibition of Phagocytosis by Silibinin in Mouse Macrophages.

This study investigated the effects of silibinin, derived from milk thistle (Silybum marianum), on lipopolysaccharide (LPS)-induced morphological changes in mouse macrophages. Silibinin was treated at various doses and time points to assess its effects on macrophage activation, including morphological changes and phagocytosis. Silibinin effectively inhibited LPS-induced pseudopodia formation and size increase, while unstimulated cells remained round. Silibinin's impact on phagocytosis was dose- and time-dependent, showing a decrease. We explored its mechanism of action on kinases using a MAPK array. Among the three MAPK family members tested, silibinin had a limited effect on JNK and p38 but significantly inhibited ERK1/2 and related RSK1/2. Silibinin also inhibited MKK6, AKT3, MSK2, p70S6K, and GSK-3ß. These findings highlight silibinin's potent inhibitory effects on phagocytosis and morphological changes in macrophages. We suggest its potential as an anti-inflammatory agent due to its ability to target key inflammatory pathways involving ERK1/2 and related kinases. Overall, this study demonstrates the promising therapeutic properties of silibinin in modulating macrophage function and inflammation.

Evaluation of humoral immune response after ChAdOx1 nCoV-19 vaccination among health care workers.

We assessed the immunogenicity of ChAdOx1 nCoV-19 vaccination by evaluating the levels of SARS-CoV-2 IgG after vaccination and investigated the effect of diverse factors such as gender, age, and adverse reactions after vaccination. The study included a total of 1028 serum samples from 452 healthcare workers. SARS-CoV-2 IgG levels were assessed using the SARS-CoV-2 IgG II Quant assay. Participants completed a questionnaire regarding the intensity and duration of adverse reactions after vaccination. The seropositive rates after the first and second doses were 95.5% and 100%, respectively. The median antibody levels after the second dose showed a 4.2-fold increase compared with the first. Five months after the second dose, the median antibody levels decreased by 3.5-fold. The antibody levels in men were lower than those in women after the first dose and were higher after the second dose. There was no difference according to age groups after the first dose, but after the second dose, in subjects aged 50 and above, the rise in antibody levels was less than that in other age groups. The antibody levels among participants with moderate or severe symptoms were significantly higher than those among participants with mild symptoms after the first dose. There were no statistically significant differences according to the duration of symptoms. We could assume that different age groups and genders might have different immunogenicity following vaccination. The intensity of adverse symptoms was positively correlated with the antibody levels, implying that higher immunogenicity is related to the intensity of adverse symptoms after vaccination.

Natural Killer Cell Activity Test Helps to Suspect Aggressive Natural Killer Cell Leukemia - Diagnostic Challenge.

Aggressive natural killer cell leukemia (ANKL) is a rare disease with an aggressive clinical course. We aimed to assess the clinicopathological characteristics of the difficult to diagnose ANKL. During ten years, nine patients with ANKL were diagnosed. All the patients exhibited aggressive clinical course and underwent the BM study to rule out lymphoma and hemophagocytic lymphohistiocytosis (HLH). BM examination showed varying degrees of infiltration of neoplastic cells, which were mainly positive for CD2, CD56, cytoplasmic CD3 and EBV in situ hybridization. Five BM aspirates showed histiocytic proliferation with active heomphagocytosis. Normal or increased NK cell activity test results were obtained from 3 patients who were available for testing. Four had multiple BM studies until diagnosis. An aggressive clinical course and positive EBV in situ hybridization, often with associated secondary HLH, should raise the suspicion of an ANKL. Conducting additional supplementary tests such as NK cell activity and NK cell proportion would be helpful for the diagnosis of ANKL.

Human embryonic stem cell-specific role of YAP in maintenance of self-renewal and survival.

Human embryonic stem cells (hESCs) have unique characteristics, such as self-renewal and pluripotency, which are distinct from those of other cell types. These characteristics of hESCs are tightly regulated by complex signaling mechanisms. In this study, we demonstrate that yes-associated protein (YAP) functions in an hESC-specific manner to maintain self-renewal and survival in hESCs. hESCs were highly sensitive to YAP downregulation to promote cell survival. Interestingly, hESCs displayed dynamic changes in YAP expression in response to YAP downregulation. YAP was critical for the maintenance of self-renewal. Additionally, the function of YAP in maintenance of self-renewal and cell survival was hESC-specific. Doxycycline upregulated YAP in hESCs and attenuated the decreased cell survival induced by YAP downregulation. However, decreased expression of self-renewal markers triggered by YAP downregulation and neural/cardiac differentiation were affected by doxycycline treatment. Collectively, the results reveal the mechanism underlying the role of YAP and the novel function of doxycycline in hESCs.

Photobiomodulation of Neurogenesis through the Enhancement of Stem Cell and Neural Progenitor Differentiation in the Central and Peripheral Nervous Systems.

Photobiomodulation (PBM) is the regulation of biological processes using light energy from sources such as lasers or light-emitting diodes. Components of the nervous system, such as the brain and peripheral nerves, are important candidate PBM targets due to the lack of therapeutic modalities for the complete cure of neurological diseases. PBM can be applied either to regenerate damaged organs or to prevent or reduce damage caused by disease. Although recent findings have suggested that neural cells can be regenerated, which contradicts our previous understanding, neural structures are still thought to have weaker regenerative capacity than other systems. Therefore, enhancing the regenerative capacity of the nervous system would aid the future development of therapeutics for neural degeneration. PBM has been shown to enhance cell differentiation from stem or progenitor cells to near-target or target cells. In this review, we have reviewed research on the effects of PBM on neurogenesis in the central nervous system (e.g., animal brains) and the peripheral nervous system (e.g., peripheral sensory neural structures) and sought its potential as a therapeutic tool for intractable neural degenerative disorders.

Multi-Wavelength Photobiomodulation Ameliorates Sodium Iodate-Induced Age-Related Macular Degeneration in Rats.

Age-related macular degeneration (AMD) is a global health challenge. AMD causes visual impairment and blindness, particularly in older individuals. This multifaceted disease progresses through various stages, from asymptomatic dry to advanced wet AMD, driven by various factors including inflammation and oxidative stress. Current treatments are effective mainly for wet AMD; the therapeutic options for dry AMD are limited. Photobiomodulation (PBM) using low-energy light in the red-to-near-infrared range is a promising treatment for retinal diseases. This study investigated the effects of multi-wavelength PBM (680, 780, and 830 nm) on sodium iodate-induced oxidatively damaged retinal tissue. In an in vivo rat model of AMD induced by sodium iodate, multi-wavelength PBM effectively protected the retinal layers, reduced retinal apoptosis, and prevented rod bipolar cell depletion. Furthermore, PBM inhibited photoreceptor degeneration and reduced retinal pigment epithelium toxicity. These results suggest that multi-wavelength PBM may be a useful therapeutic strategy for AMD, mitigating oxidative stress, preserving retinal integrity, and preventing apoptosis.

Increased EAT volume after anthracycline chemotherapy is associated with a low risk of cardiotoxicity in breast cancer.

PURPOSE: Chemotherapy-induced cardiotoxicity is a critical issue for patients with breast cancer. Change of epicardial adipose tissue (EAT) is associated with cardiac dysfunction. The objective of this study was to investigate the relationship between EAT and chemotherapy-induced cardiotoxicity. METHODS: This retrospective study analyzed EAT on chest computed tomography (CT) of patients with early breast cancer using automatic, quantitative measurement software between November 2015 and January 2020. Changes in EAT before and after initiation of chemotherapy were compared according to the type of anticancer drug. Subclinical cardiotoxicity was defined as worsening ≥ 10% in left ventricular ejection fraction to an absolute value > 50% with a lower limit of normal measured with standard echocardiography. RESULTS: Among 234 patients with breast cancer, 85 were treated with adjuvant anthracycline-based (AC) and 149 were treated with non-anthracycline-based (non-AC) chemotherapy. There was a significant increase in EAT volume index (mL/kg/m2) at the end of chemotherapy compared to that at the baseline in the AC group (3.33 ± 1.53 vs. 2.90 ± 1.52, p < 0.001), but not in the non-AC group. During the follow-up period, subclinical cardiotoxicity developed in 20/234 (8.6%) patients in the total population [13/85 (15.3%) in the AC group and 7/149 (4.8%) in the non-AC group]. In the multivariable analysis, EAT volume index increment after chemotherapy was associated with a lower risk of subclinical cardiotoxicity in the AC group (Odds ratio: 0.364, 95% CI 0.136-0.971, p = 0.044). CONCLUSIONS: Measurement of EAT during anthracycline-based chemotherapy might help identify subgroups who are vulnerable to chemotherapy-induced cardiotoxicity. Early detection of EAT volume change could enable tailored chemotherapy with cardiotoxicity prevention strategies.

Establishment of a useful in vitro decidual induction model using eCG-primed nonpregnant mouse endometrial stromal cells†.

Uterine endometrial differentiation is essential for developmental continuity and female health. A convenient in vitro model mimicking the physiological status is needed to effectively evaluate implantation and uterine response mechanisms. Thus, we developed a promising in vitro model, the FSS (FSH mimic-stimulated synchronized) model, by using primary mouse uterine stromal cells (mUSCs) obtained from equine chorionic gonadotropin (eCG)-primed mice. These mUSCs could be differentiated into decidualized cells with 17 beta-estradiol (E2) and progesterone (P4). The pregnancy day 4 (PD4) model, in which mUSCs are obtained at day 4 of pregnancy, was used as a control. The cell shape index and polyploidy rates were similar between the two models. The staining intensities of lipids and glycogen were significantly higher in the induced groups in both models but stronger in the FSS model than in the PD4 model. The expression levels of AP-TNAP, cathepsin L, Prl8a2, Gja1, Cebpb, and Igfbp1 were increased at 24 h after decidual induction. PR-alpha and PR-beta levels were also increased at 24 h after decidual induction in both models. These results indicate that the FSS model provides a convenient method for obtaining USCs that are usable for various experimental approaches due to their physiological competence and flexibility for triggering induction. This may serve as a model system for the study of pathogeneses originating from the endometrium or communication with other tissues and lead to a better understanding of embryo implantation mechanisms. Furthermore, the results of this study will be integral for further refinements of 3D uterine culture manipulation techniques.

Designed Amyloid Fibers with Emergent Melanosomal Functions.

Short peptides designed to self-associate into amyloid fibers with metal ion-binding ability have been used to catalyze various types of chemical reactions. This manuscript demonstrates that one of these short-peptide fibers coordinated with CuII can exhibit melanosomal functions. The coordinated CuII and the amyloid structure itself are differentially functional in accelerating oxidative self-association of dopamine into melanin-like species and in regulating their material properties (e.g., water dispersion, morphology, and the density of unpaired electrons). The results have implications for the role of functional amyloids in melanin biosynthesis and for designing peptide-based supramolecular structures with various emergent functions.

Inner Ear Symptoms Are Prevalent in Patients with High Head Abbreviated Injury Scale Scores after Blunt Head Trauma.

INTRODUCTION: The purpose of this article was to determine the prevalence of inner ear symptoms in patients with blunt head trauma and to explore whether the severity of head trauma was associated with the incidence of such symptoms. METHODS: We performed a retrospective review of 56 patients admitted with blunt head trauma who underwent audiovestibular evaluation within 1 month after injury. Two scales were used to measure the severity of trauma; these were the Glasgow Coma Scale (GCS) and the Head Abbreviated Injury Scale (H-AIS). Patients with sensorineural-type hearing loss, or dizziness with nystagmus, were considered to have inner ear symptoms. RESULTS: About half of all patients (45%) with blunt head trauma showed trauma-related inner ear symptoms. Patients with inner ear symptoms were significantly more likely to have H-AIS scores ≥4 than those without inner ear symptoms (p = 0.004), even without concomitant temporal bone fracture (p > 0.05). Also, patients with inner ear symptoms required a statistically significantly longer time (measured from admission) before undergoing their ontological evaluations than did those without such symptoms (p = 0.002), possibly due to prolonged bed rest and use of sedatives. CONCLUSION: Thus, detailed history-taking and early evaluation using trauma scales are essential for all patients suffering from severe head trauma. It may be necessary to initiate early treatment of traumatic inner ear diseases.

Neutrophil-lymphocyte ratio and carotid plaque burden in patients with essential thrombocythemia and polycythemia vera.

BACKGROUND AND AIMS: Chronic inflammation plays a critical role in the pathogenesis of myeloproliferative neoplasm (MPN), and inflammatory conditions are closely related to the development and exacerbation of atherosclerosis. This study aimed to compare carotid plaque burden and neutrophil-lymphocyte ratio (NLR) in the essential thrombocythemia (ET)/polycythemia vera (PV) and control groups. METHODS AND RESULTS: We retrospectively assessed carotid plaque burden and NLR in patients with ET/PV between January 2010 and September 2021 and propensity-score matched these patients to control subjects from the general population. All patients underwent carotid imaging using carotid ultrasonography for atherosclerosis screening. After 3:1 propensity-score matching, 140 patients in the control group were matched to 51 patients in ET/PV group. The mean NLR was significantly higher in the MPN group than in the control group (4.77 ± 3.96 vs. 1.93 ± 1.03, p < 0.001). The carotid plaque score was also higher in MPN group than in the control group (2.37 ± 1.47 vs. 1.94 ± 1.17, p = 0.038). CONCLUSION: Patients with PV/ET show a higher NLR and carotid plaque burden than the normal population. This reflected that PV/ET was a highly inflammatory and atherosclerotic condition expressing potentially increased cardiovascular risk.

Successful Treatment of Thrombotic Thrombocytopenic Purpura in a Patient with Mixed Connective Tissue Disease.

BACKGROUND: Although the survival rate of thrombocytopenic purpura (TTP) has increased significantly due to the introduction of therapeutic plasma exchange (TPE). TTP in patients with mixed connective tissue disease (MCTD) has a very high mortality rate and a very small number of reported cases. In TTP, daily TPE is administered until a treatment response is achieved; however, in practice, TPE is often not performed for such long durations. METHODS: We report a case of TTP with MCTD in a female patient. She had developed thrombocytopenia and hemolytic anemia 9 months after delivery. She had status epilepticus and lapsed into a coma. RESULTS: The patient was successfully treated with extended sessions of TPE with corticosteroids and rituximab. CONCLUSIONS: Although the TTP regimen has not yet been established and remains controversial, this report demonstrates the importance of continuing daily TPE until achieving a treatment response.