title: Pulmonary tumor thrombotic microangiopathy: report of 3 cases and review of the literature.
abstract: Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare clinical entity where tumor cell embolisms in pulmonary circulation induce thrombotic microangiopathy (TMA), respiratory failure, and subacute cor pulmonale.We describe 3 cases of PTTM that presented as the initial manifestation of metastatic gastric adenocarcinoma with TMA and pulmonary infiltrates.All 3 cases had similar clinical and laboratory features, which included moderate thrombocytopenia without renal failure, hemolysis with extremely high serum lactate dehydrogenase levels, leukoerythroblastosis in peripheral blood smear, altered coagulation tests, lymphadenopathies, and interstitial pulmonary infiltrates. All patients died within 2 weeks of diagnosis. Two cases were initially misdiagnosed as idiopathic thrombotic thrombocytopenic purpura and treated with plasma exchange with no response. One patient had bone marrow infiltration by malignant cells. Autopsies revealed PTTM associated with gastric disseminated adenocarcinoma (signet-ring cell type in 2 patients and poorly differentiated type in 1).PTTM should be considered in the differential diagnosis of patients with fulminant microangiopathic hemolytic anemia, such as atypical thrombotic thrombocytopenic purpura, mainly those with pulmonary infiltrates, disseminated intravascular coagulation, or Trousseau syndrome.
authors.affiliation: From the Hematology Department (EG, MTC, JE); Medical Intensive Care Unit (SF, PC, JMN); Pathology Department (DM, JR); Internal Medicine Department (XB); and Hemotherapy-Hemostasis Department (AP), Hospital Clinic, Barcelona, Spain.
authors.forename: Eukene
authors.initials: E
authors.lastname: Gainza
authors.forename: Sara
authors.initials: S
authors.lastname: Fernández
authors.forename: Daniel
authors.initials: D
authors.lastname: Martínez
authors.forename: Pedro
authors.initials: P
authors.lastname: Castro
authors.forename: Xavier
authors.initials: X
authors.lastname: Bosch
authors.forename: José
authors.initials: J
authors.lastname: Ramírez
authors.forename: Arturo
authors.initials: A
authors.lastname: Pereira
authors.forename: María T
authors.initials: MT
authors.lastname: Cibeira
authors.forename: Jordi
authors.initials: J
authors.lastname: Esteve
authors.forename: Josep M
authors.initials: JM
authors.lastname: Nicolás
mesh_terms: D000230:Adenocarcinoma / Q000150:complications* / Q000473:pathology; D000328:Adult; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008168:Lung / Q000098:blood supply; D008171:Lung Diseases / Q000175:diagnosis / Q000209:etiology*; D008297:Male; D009362:Neoplasm Metastasis; D013274:Stomach Neoplasms / Q000150:complications* / Q000473:pathology; D057049:Thrombotic Microangiopathies / Q000175:diagnosis / Q000209:etiology*; D055815:Young Adult