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Anaphylaxis and lack of efficacy: case report A 63-year-old woman developed an allergic transfusion reaction in the form of anaphylaxis during treatment with plasma for immune-mediated thrombotic thrombocytopenic purpura. Additionally, she exhibited lack of efficacy during treatment with methylprednisolone for allergic transfusion reaction. The woman, who had a history of gastroesophageal reflux disease, Barrett’s oesophagus and hypertension, presented with acute confusion after several dental extractions (performed 6 days previously). At admission, she had mild bleeding at the surgical sites. In the emergency department (on day 0), she had multiple ecchymoses. Therefore, she was transfused with apheresis platelets and RBCs. Her blood smear test indicated thrombotic thrombocytopenic purpura. Subsequently, she was transferred to another hospital for plasma exchange therapy. On day 2 after the initial presentation, she started receiving plasma [fresh frozen plasma] therapy [route and dosage not stated]. The same day, she also received prednisone concomitantly. Investigation confirmed the diagnosis of immune-mediated thrombotic thrombocytopenic purpura. However, during plasma therapy, she developed hives. Hence, the woman received a single dose of diphenhydramine, which resulted in some relief. Subsequently, the woman’s plasma exchange therapy was resumed. However, she developed hypotension, wheezing, flushing and red discoloration and angioedema. A diagnosis of allergic transfusion reaction in the form of anaphylaxis. Hence, she was treated with IV bolus of methylprednisolone 125mg and was transferred to the ICU. Despite treatment with methylprednisolone, her hypotension persisted. Hence, she received epinephrine and oxygen therapy. Within a few hours, her symptoms resolved. She received 0.45 of the total plasma volume. Subsequent plasma exchange was contemplated to be unsafe. The next morning, she started receiving IV methylprednisolone 60mg four times a day for 9 days, along with caplacizumab and rituximab. Her treatment with caplacizumab was continued for 7 days. On day 12, she had a brisk response with the platelet count, which had peaked. Her haemoglobin level also increased. During treatment, she felt better, and her ADAMTS13 activity increased. She had developed herpes labialis [aetiology not stated], which was successfully treated with unspecified antiviral therapy. On day 12, her methylprednisolone dose was tapered to 60mg twice daily. Subsequently, she was discharged from the hospital on a prednisone taper. Later, she received several dosages of rituximab. At the last visit (on day 114), she was clinically well. Irani MS, et al. Caplacizumab for treatment of thrombotic thrombocytopenic purpura in a patient with anaphylaxis to fresh-frozen plasma. Transfusion 60: 1666-1668, No. 8, 803506074 Aug 2020. Available from: URL: http://doi.org/10.1111/trf.15823

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Reactions 10 Oct 2020 No. 1825