Complete response to eculizumab in atypical hemolytic uremic syndrome with homozygous C3 mutation
American Journal of the Medical Sciences
; 365(Supplement 1):S368-S369, 2023.
Article
in English
| EMBASE | ID: covidwho-2234720
ABSTRACT
Case Report Atypical Hemolytic Uremic Syndrome (atypical HUS) is a rare and severe form of thrombotic microangiopathy (TMA) characterized by thrombocytopenia, intravascular hemolysis, and acute kidney injury with an incidence of 1 per million.1 Dysregulation and overactivation of the complement alternative pathway due to genetic mutations have been detected in 40-60% of patients with sporadic or familial atypical HUS.2,4 Triggers include viral illness, pregnancy, malignancy, sepsis, or sporadically with no known inciting event.1 Atypical HUS is a severe disease with a 2-10% risk of mortality, 33% risk of end-stage renal failure, and 50% chance of relapse.5 A 24-year-old female with prior history of atypical HUS at the age of 16 (with response to plasmapheresis) presented to the ER with a 5-day history of fever, chills, sore throat, nausea, vomiting, and dark urine. She tested positive for COVID-19. The exam revealed scleral icterus and scattered petechiae. Labs demonstrated nadir hemoglobin (Hgb) of 9.2 g/dL, platelet count of 52 000k/uL, haptoglobin < 30 mg/dL, peak LDH 1128U/L and creatinine 4.62 mg/dL. Urinalysis is consistent with hemoglobinuria. Schistocytes were noted on the peripheral smear. Rapid streptococcal antigen test and C3, C4, and IgA levels were unremarkable. Chest X-Ray, X-ray KUB, and ultrasound abdomen were unremarkable. The pregnancy test was negative. ADAMTS13 was >100%. Genetic analysis after the initial episode at age 16 revealed autosomal recessive inheritance c.193A > c gene mutations in C3. The patient received IV fluids, ceftriaxone for cystitis, and two units of Fresh Frozen Plasma. She initiated treatment with eculizumab. She also received the MENVEO and meningitis B vaccine per protocol due to the risk of meningitis from terminal complement deficiencies. After 4 infusions of eculizumab, patient's labs improved to platelet count of 307 000 k/uL, Hgb 12.2 g/ dL (nadir 9.2 g/dL), haptoglobin 78 mg/dL normalization of LDH and improved creatinine. Atypical HUS is a rare form of TMAwith mutations in C3 noted in 5% of cases. Complement cascade dysfunction leads to endothelial deposits and microvasculature damage. The resulting prothrombotic state causes obstructive microvascular thrombi predominantly affecting the kidneys but can cause multiorgan dysfunction. The SARS-CoV-2 virus may precipitate atypical HUS relapse due to endothelial damage and complement activation further intensified in patients with existing complement aberrations. Plasma exchange remains a standard of care for atypical HUS, as it effectively removes the antibodies and other proteins. Eculizumab a humanized monoclonal IgG antibody binds to complement proteins, preventing cleavage into C5a and C5b blocking C5b-9(MAC) activation. In patients with CFH, CFI, C3, and CFB mutations, eculizumab is the preferred intervention. Copyright © 2023 Southern Society for Clinical Investigation.
abdomen; acute kidney failure; adolescent; adult; atypical hemolytic uraemic syndrome; autosomal recessive inheritance; cancer patient; cancer recurrence; case report; chill; clinical article; complement activation; complement alternative pathway; complement deficiency; conference abstract; coronavirus disease 2019; cystitis; drug therapy; end stage renal disease; endothelium lesion; female; fever; gene expression; gene mutation; genetic analysis; genetic association; genetic susceptibility; health care quality; hemoglobinuria; homozygosity; human; human cell; human tissue; immunoglobulin blood level; incidence; intravascular hemolysis; jaundice; meningitis; microvasculature; mortality risk; multiple organ failure; nausea and vomiting; nonhuman; petechia; plasma exchange; plasmapheresis; platelet count; precipitation; pregnancy; pregnancy test; remission; schistocyte; sclera; sepsis; Severe acute respiratory syndrome coronavirus 2; sore throat; thorax radiography; thrombocytopenia; thrombus; ultrasound; urinalysis; X ray; young adult; ceftriaxone; complement; complement component C5a; complement component C5b; complement membrane attack complex; creatinine; eculizumab; endogenous compound; fresh frozen plasma; haptoglobin; hemoglobin; immunoglobulin A; immunoglobulin G antibody; Meningococcus vaccine; Streptococcus antigen; unclassified drug; von Willebrand factor cleaving proteinase
Full text:
Available
Collection:
Databases of international organizations
Database:
EMBASE
Type of study:
Observational study
/
Prognostic study
Topics:
Vaccines
Language:
English
Journal:
American Journal of the Medical Sciences
Year:
2023
Document Type:
Article
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