Myocarditis and right atrial thrombus in a patient with Thrombotic thrombocytopenic purpura- CASE REPORT

Myocarditis and right atrial thrombus in a patient with Thrombotic thrombocytopenic purpura- CASE REPORT | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Myocarditis and right atrial thrombus in a patient with Thrombotic thrombocytopenic purpura- CASE REPORT JAIDEEP DEY, AMITA GARG, ARIF MUSTAQUEEM, MAN MOHAN MEHNDIRATTA, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6743321/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Thrombotic thrombocytopenic purpura is a very rare form of thrombotic microangiopathy with an annual incidence ranging between 1.5-6 cases per million adult individuals. Cardiac involvement in thrombotic thrombocytopenic purpura may be diagnosed in up to a quarter of these patients, often associated with an adverse prognosis. Though cardiac microvascular thrombosis is most commonly noted, macrovascular thrombosis may also occur. Case Presentation: We report about a young male patient with obesity and hypertension who presented with recurrent ischemic strokes. He was found to be having severe hemolytic anemia along with severe thrombocytopenia. A diagnosis of thrombotic thrombocytopenic purpura was confirmed due to almost undetectable levels of a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 levels. His troponin I level was also elevated while having no cardiac symptoms. He was diagnosed with asymptomatic myocarditis along with right atrial thrombosis which was confirmed with transesophageal echocardiography and cardiac magnetic resonance imaging. This is probably the first reported case of concomitant myocarditis with intracardiac thrombosis in a patient of thrombotic thrombocytopenic purpura. Prompt initiation of plasma exchange therapy followed by corticosteroids, rituximab and aspirin led to disease remission. Conclusion: Intensivists and cardiologists must be aware of the varied presentations associated with thrombotic thrombocytopenic purpura. Early diagnosis and cardiac evaluation is essential for ensuring a favorable outcome in these critically ill patients. Thrombotic thrombocytopenic purpura Right atrial thrombus Myocarditis Troponin I Plasma exchange therapy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a type of thrombotic microangiopathy (TMA) [ 1 ]. It is a rare disease, with reported annual incidence between 1.5-6 cases per million adults [ 2 ]. The classic clinical pentad of TTP (fever, neurological manifestations, thrombocytopenia, microangiopathic hemolytic anemia and renal failure) is seen in only 7–10% of patients, while cardiac involvement is noted in up to 25% of patients [ 3 ]. Cardiac involvement in TTP is manifested mainly in the form of microvascular thrombosis associated myocardial injury. We hereby report about an unusual presentation of a young TTP patient with myocarditis and right atrial thrombus but without cardiac symptoms. CASE PRESENTATION A 35-year-old male patient presented to our hospital with 1-day history of sudden onset dizziness, dysphasia, blurring of vision in right eye and deviation of angle of mouth to the left side. His past medical history was significant for obesity and hypertension. He had had a previous episode of ischemic stroke 5 months prior to the current presentation. At that time, he was diagnosed with right middle cerebral artery (MCA) territory infarction and had been thrombolysed with Alteplase at another institution. His clinical course was complicated by development of intraparenchymal hemorrhage in right parietal lobe and subarachnoid hemorrhage along bilateral frontal lobes. He was managed conservatively with medical therapy and had an uneventful recovery till the present admission. Unfortunately, previous clinical records were not available with the patient. He had no history of substance abuse or any significant family history of atherosclerotic cardiovascular disease. His current medications included- aspirin, clopidogrel, rosuvastatin, olmesartan, divalproex sodium, lacosamide, flunarizine, naproxen, domperidone, escitalopram and clonazepam. At presentation, patient was afebrile, conscious, oriented and obeying verbal commands. His heart rate was 98/minute, regular with a blood pressure of 120/70 mmHg. General physical examination was significant for presence of pallor. Nervous system examination revealed presence of deviation of angle of mouth to the left side and cerebellar signs (dysarthria). No gross motor or sensory deficits were noted. Magnetic resonance imaging (MRI) of the brain revealed, multiple areas of altered signal intensity in right caudate nucleus and right cerebellar hemisphere appearing hyperintense on diffusion weighted imaging (DWI), suggestive of acute infarct (Fig. 1 ). Small foci of DWI hyperintensities were noted in right parietal lobe, consistent with subacute infarction. Magnetic resonance angiography did not reveal any flow limiting stenosis in bilateral carotid and vertebral arteries. The hematological and blood chemistry investigations are outlined in Table 1 . Complete blood count showed severe anemia (hemoglobin- 5.7 gm/dl), leukocytosis (12.8 x 10 3 /µl) with a leftward shift and severe thrombocytopenia (platelet count- 8.0 x 10 3 /µl). Peripheral blood smear showed a dimorphic picture with numerous schistocytes (6.0%), nucleated red blood cells, polychromatophils and tear drop cells. Marked thrombocytopenia and neutrophilic leukocytosis were also noted. Reticulocyte count (14.6%) and serum lactate dehydrogenase (LDH-1059.3 U/l) were increased, while serum haptoglobin was markedly reduced (< 30.0 mg/dl). Hepatic and renal function tests were normal. Infectious disease screening, blood and urine cultures, viral markers, autoimmune markers and inherited prothrombotic state screening tests were negative. A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13) activity in blood was almost undetectable (< 0.2%, biological reference interval- 60.6-130.6%). High-sensitive troponin I was raised (546.0 pg/ml, biological reference interval- <34.2 pg/ml). Table 1 Hematological and biochemical parameters of the patient at presentation and during course of therapy. Parameter On admission Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 At 3 weeks At 4 weeks Hemoglobin (gm/dl) 5.7 7.3 8.0 8.2 9.7 10.8 9.9 9.5 10.4 11.6 12.1 Packed cell volume (%) 19.2 24.1 26.6 28.6 32.9 36.0 33.3 30.9 34.1 - - Total leukocyte count (x10 3 /µl) 12.8 19.8 23.6 16.1 12.0 11.1 10.4 9.7 10.4 11.3 11.5 Platelet count (x10 3 /µl) 8.0 16.0 20.0 100.0 119.0 155.0 164.0 192.0 243.0 160.0 228.0 Reticulocyte count (%) 14.6 - - - - 11.6 - - - - - Lactate dehydrogenase (U/l) 1059.3 - - - - 259.1 - - - - - Haptoglobin (mg/dl) < 30.0 Blood urea (mg/dl) 26.6 Estimated glomerular filtration rate (ml/min/1.73m 2 ) 102.1 Creatinine (mg/dl) 0.85 Bilirubin (mg/dl) 1.3 (Direct- 0.3, Indirect- 1.0) SGOT (U/l) 38.7 SGPT (U/l) 22.1 ALP (U/l) 91.6 GGT (U/l) 73.0 ADAMTS13 activity (%) < 0.2% High-sensitive Troponin I (pg/ml) 546.0 ADAMTS13- A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 ALP- Alkaline phosphatase GGT- Gamma-glutamyl transferase SGOT- Serum glutamic-oxaloacetic transaminase SGPT- Serum glutamate-pyruvate transaminase The electrocardiogram (ECG) at presentation showed normal sinus rhythm with no significant ST/T changes (Fig. 2 A). Chest roentgenogram demonstrated no significant abnormality with central venous catheter (CVC) line visualized in-situ (Fig. 2 B). Ultrasonography of abdomen was significant for grade I fatty liver with no other abnormality detected. Cardiac imaging studies Transthoracic echocardiography (TTE) revealed, an echogenic, 2.8 x 1.8 cms sized mobile, lobulated right atrial (RA) mass, in proximity to superior portion of interatrial septum. A likelihood of thrombus/neoplastic mass was considered (Fig. 3 , videos 1–3). RA was mildly dilated. Mild 2 + tricuspid regurgitation was noted with an estimated pulmonary artery systolic pressure of 40 mmHg. There were no left ventricular (LV) regional wall motion abnormalities and LV ejection fraction was 55%. Grade I diastolic dysfunction was noted. Cardiac valves were morphologically normal. There was no pericardial pathology. Transesophageal echocardiography (TEE) confirmed the presence of a mobile RA mass with point of attachment at the inferior vena cava (IVC) junction into RA with protrusion into RA cavity (Figs. 4 A-C, videos 4–7). The mass had a claw-like shape with lobulations at margins. Size of the mass was 3.9 x 2.1 cms. The appearance and location pointed towards the provisional diagnosis of thrombus. No other mass lesion was noted in any other cardiac chamber. Cardiac MRI (CMR) showed a low signal intensity lesion in RA, close to IVC opening and partially extending into it, with no contrast enhancement, suggestive of thrombus (Figs. 5 A-C). A non-specific delayed gadolinium enhanced area (size 2.1 x 0.9 cms) was noted in posterolateral LV in subepicardial location (Figs. 5 D-F). There were no myocardial perfusion deficits or wall motion abnormalities detected. A whole-body positron emission tomography/computed tomography (PET/CT) scanning did not reveal any metabolically active lesion. Clinical course In view of a young patient presenting with recurrent ischemic stroke, a prothrombotic state was considered. Clinical presentation along with hematological and biochemical results was suggestive of TMA. An almost undetectable blood level of ADAMTS13, narrowed down the diagnosis towards TTP. Patient was started on plasmapheresis (PEX) in consultation with the hematology team. Oral corticosteroid (Prednisolone) was thereafter commenced. Rituximab (anti-CD20 monoclonal antibody) therapy was also initiated. He had gradual improvement in hematological and biochemical parameters during 5 sessions of PEX and 4 cycles of rituximab infusions over the 4-week treatment duration (Table 1 ). Platelet counts and serum LDH levels normalized over the course of therapy. There were no subsequent thrombotic episodes. Aspirin was initiated once platelet counts improved to > 50 x 10 3 /µl. A repeat TEE after 3- and 4-weeks post presentation showed persistence of the RA thrombus along with a distinct reduction in its volume and friability (Figs. 4 D-I). The patient is presently in clinical remission. He is on regular follow-up and planned for further management in accordance with multi-speciality consultation. DISCUSSION We report the case of a young male patient with TTP who presented with recurrent ischemic strokes along with cardiac involvement. TTP manifests due to an inherited or acquired deficiency of ADAMTS13. ADAMTS13 is a metalloprotease which cleaves large multimers of von Willebrand factor (VWf) under high shear stress, thereby preventing platelet aggregation and thrombosis. ADAMTS13 deficiency leads to accumulation of large multimers of VWf, resulting in uncontrolled platelet adhesion and aggregation with subsequent intravascular microthrombosis [ 2 ]. The unique feature in our patient was that, despite presenting with neurological symptoms, he had concomitant subclinical cardiac involvement associated with both microvascular (focal myocarditis) and macrovascular thrombosis (RA mass). The PLASMIC score (Platelet count, hemolysis, active cancer, solid organ or stem cell transplant, international normalized ratio and creatinine), which is an easily calculable risk score to predict severe ADAMTS13 deficiency was 6, indicating high risk of severe deficiency which was subsequently confirmed on lab testing [ 4 ]. Cardiac involvement in TTP may present with troponin elevation, ECG abnormalities, heart failure, arrhythmias, cardiogenic shock or sudden cardiac death. Occasionally, presentation may be subclinical. Cardiac manifestations may be prominent in severe forms of TTP and can herald an aggressive disease course with poor prognosis. In a study involving 98 critically ill patients with severe TTP, cardiac involvement was noted in 91% of the patients [ 5 ]. Among these patients, troponin elevation was noted as the most common presentation (72%) while isolated troponin elevation was seen in 20% of patients [ 5 ]. Myocarditis can develop in TTP due to thrombus formation in the microvasculature [ 6 ]. Though there were no significant ECG changes in our patient, an elevated troponin level along with CMR evidence of myocarditis indicated myocardial injury. RA thrombus in our case is an unusual finding considering the backdrop of TTP. Although macrovascular thrombosis, specifically deep vein thrombosis (DVT) has been reported in TTP, RA thrombus is distinctly uncommon [ 7 ]. In a recent comprehensive review of TTP patients over a 12-year period between 2010–2022, involving 221 observational studies, there were no reported cases with RA thrombosis [ 8 ]. A literature search in Pubmed® as of April 2025 did not return any results pertaining to RA thrombus in TTP patients. Ours is probably the first reported case with this presentation. CVC line insertion could have predisposed to catheter associated DVT with subsequent progression into right atrium. In a retrospective study involving 55 patients of TMA admitted in intensive care over a 6-year period, 21 patients had DVT, of which 13 patients had indwelling CVC in-situ [ 9 ]. Factors associated with DVT included- undetectable ADAMTS13 activity level, cardiac involvement and TMA disease flare-up. Particularly, TTP associated ADAMTS13 deficiency and patients with cardiac manifestations of TMA were more susceptible to DVT [ 9 ]. As these patients frequently require CVC access, careful monitoring for signs or symptoms of DVT must be ensured including venous doppler studies whenever indicated. In hindsight, most likely the first episode of stroke in our patient was precipitated by TTP. Misdiagnosis of TTP, particularly during the initial presentation, may occur in up to 20% of patients [ 10 ]. In a retrospective study involving 423 patients of acquired TTP (diagnosed over a 14 year period), the following clinical characteristics were associated with misdiagnosis of TTP- delayed time to clinical diagnosis, female gender, history of autoimmune disorder, organ involvement before TTP diagnosis, a higher hemoglobin level, low or undetectable schistocytes, positive direct antiglobulin test, acute kidney injury stage 2 and a positive antinuclear antibody (ANA) test [ 10 ]. PEX along with oral corticosteroids and rituximab therapy showed a sustained hematological improvement in our patient (Tables 1 , 2 ). Anticoagulation therapy was contemplated on improvement in platelet counts, however, due to recent history of intracranial hemorrhage, this was immediately not considered, after discussion between the neurology and hematology teams. Low dose aspirin was initiated once platelet counts increased to > 50 x 10 3 /µl in accordance with current guidelines [ 11 , 12 , 13 ]. Table 2 Timeline of patient events: from presentation till achievement of disease remission. Timeline Events 5 months prior to current admission Ischemic stroke thrombolysed with alteplase; associated with subsequent intracranial hemorrhage (medically managed) Day 0 Presented with new onset ischemic stroke associated with severe thrombocytopenia and severe hemolytic anemia Day 1 Investigations reveal significantly reduced ADAMTS13 activity level in blood, elevated cardiac troponin and right atrial mass lesion (thrombus) Day 2 Initiation of Plasma exchange therapy (continued for 5 days), corticosteroids (Prednisolone) initiated on completion of plasma exchange Day 5 Platelet levels normalized and serum LDH levels reduced by 76% Day 6 Initiation of weekly Rituximab therapy 5th week Completion of 4 weeks of Rituximab therapy On tapering doses of oral corticosteroid therapy Patient presently in clinical remission Cardiac involvement in TTP has important significance in patient management. As presentation may be asymptomatic, ECG, troponin levels and TTE must be performed in all suspected cases as soon as possible. An elevated cardiac troponin level confers a higher risk of mortality and treatment refractoriness [ 11 , 14 ]. Clinical deterioration during the disease course warrants immediate reassessment for cardiac complications. Clinical, hematological and cardiology follow-up must be ensured in these patients in view of worse prognosis and risk of adverse cardiac events during the disease course. CONCLUSION Cardiovascular involvement is common in TTP with asymptomatic presentation and isolated cardiac troponin elevation is most frequently noted. Prompt cardiovascular assessment is indicated on presumptive diagnosis of TTP. Though microvascular thrombosis is the usual pathology, cardiac macrovascular thrombosis may also develop. In view of worsened prognosis, such patients require a more focused and multi-modality management protocol to ensure adequate treatment response. Abbreviations TTP- Thrombotic thrombocytopenic purpura TMA- Thrombotic microangiopathy MCA- Middle cerebral artery MRI- Magnetic resonance imaging DWI- Diffusion weighted imaging LDH- Lactate dehydrogenase ECG- Electrocardiogram ADAMTS13- A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 CVC- Central venous catheter TTE- Transthoracic echocardiography RA- Right atrium LV- Left ventricle TEE- Transesophageal echocardiography IVC- Inferior vena cava CMR- Cardiac MRI PET/CT- Positron emission tomography/computed tomography PEX- Plasmapheresis VWf- von Willebrand factor PLASMIC- Platelet count, hemolysis, active cancer, solid organ or stem cell transplant, international normalized ratio and creatinine DVT- Deep vein thrombosis ANA- Antinuclear antibody ALP- Alkaline phosphatase GGT- Gamma-glutamyl transferase SGOT- Serum glutamic-oxaloacetic transaminase SGPT- Serum glutamate-pyruvate transaminase Declarations Funding: The authors declare that they have not received funding from any source with respect to the preparation of this manuscript. Ethics approval and consent to participate The patient provided proper informed consent to participate in the study. Consent for publication The patient has given informed consent for the case details and any associated medical images to be published in this case report. Author Contribution Concept and design- SS, AM, JD; Recording and interpretation of imaging data- AG, JD; Patient care, lab investigation analyses- MM; Manuscript writing- JD, AG; All authors provided final approval of the manuscript. Acknowledgement We would like to express our heartfelt gratitude to Dr. T. S. Kler (Chairman & Head of Department Cardiology), faculty and staff of the Department of Radiology and all the support staff in Non-invasive Cardiology lab BLK-Max Super Speciality Hospital, New Delhi, for their assistance and support in preparing this manuscript. References Addad, V. V., Palma, L. M. P., Vaisbich M. H., et al. (2023). A comprehensive model for assessing and classifying patients with thrombotic microangiopathy: the TMA-INSIGHT score. Thromb J , 21(1), 119. https://doi.org/10.1186/s12959-023-00564-6. Sukumar, S., Lämmle, B., Cataland, S. R. (2021). Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med , 10(3), 536. https://doi.org/10.3390/jcm10030536. Cilla, N., Dallemagne, J., Vanhove, M., et al. (2020). Delayed Thrombotic Complications in a Thrombotic Thrombocytopenic Purpura Patient Treated With Caplacizumab. J Hematol , 9(3), 84–88. https://doi.org/10.14740/jh614. Vyas, A., Isaac, S., Kaur, D., et al. (2023). Role of the PLASMIC Score in the Management of Thrombotic Thrombocytopenic Purpura. Cureus , 15(3), e36188. https://doi.org/10.7759/cureus.36188. Fourmont, A. M., Zafrani, L., Mariotte, E., et al. (2018). The clinical features of cardiac involvement in patients with severe thrombotic thrombocytopenic purpura. Intensive Care Med , 44(6), 963–965. https://doi.org/10.1007/s00134-018-5216-7. Webb, J. G., Butany, J., Langer, G., et al. (1990). Myocarditis and myocardial hemorrhage associated with thrombotic thrombocytopenic purpura. Arch Intern Med , 150(7), 1535–1537. Fodil, S., Zafrani, L. (2022). Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients. J Clin Med , 11(4), 1103. https://doi.org/10.3390/jcm11041103. Du, P., Cristarella, T., Goyer, C., et al. (2024). A Systematic Review of the Epidemiology and Disease Burden of Congenital and Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Blood Med , 15, 363–386. https://doi.org/10.2147/JBM.S464365. Camous, L., Veyradier, A., Darmon, M., et al. (2014). Macrovascular thrombosis in critically ill patients with thrombotic micro-angiopathies. Intern Emerg Med , 9(3), 267–272. https://doi.org/10.1007/s11739-012-0851-4. Grall, M., Azoulay, E., Galicier, L., et al. (2017). Thrombotic thrombocytopenic purpura misdiagnosed as autoimmune cytopenia: Causes of diagnostic errors and consequence on outcome. Experience of the French thrombotic microangiopathies reference centre. Am J Hematol , 92(4), 381–387. https://doi.org/10.1002/ajh.24665. Scully, M., Rayment, R., Clark, A., et al. (2023). A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol , 203(4), 546–563. https://doi.org/10.1111/bjh.19026. Matsumoto, M., Miyakawa, Y., Kokame, K., et al, & For TTP group of Blood Coagulation Abnormalities Research Study Team, Research on Rare and Intractable diseases, Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan (2023). Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. Int. J. Hematol , 118(5), 529–546. https://doi.org/10.1007/s12185-023-03657-0. Azoulay, E., Bauer, P. R., Mariotte, E., et al. (2019). Expert statement on the ICU management of patients with thrombotic thrombocytopenic purpura. Intensive Care Med , 45(11), 1518–1539. https://doi.org/10.1007/s00134-019-05736-5. Wiernek, S. L., Jiang, B., Gustafson, G. M., et al. (2018). Cardiac implications of thrombotic thrombocytopenic purpura. World J Cardiol , 10(12), 254–266. https://doi.org/10.4330/wjc.v10.i12.254. Additional Declarations No competing interests reported. Supplementary Files movie1.avi SUPPLEMENTARY VIDEO FILES LEGENDS Video file 1. Transthoracic echocardiography (short axis) view depicting the right atrial mass lesion. movie2.avi Video file 2. Transthoracic echocardiography (apical 4 chamber) view depicting the right atrial mass lesion. movie3.avi Video file 3. Transthoracic echocardiography (subcostal) view depicting the right atrial mass lesion in close proximity to inferior vena caval drainage into right atrium. movie4.avi Video file 4. Transesophageal echocardiography (0-degree long axis) view showing the right atrial mass lesion in a linear claw like configuration. movie5.avi Video file 5. Transesophageal echocardiography (bicaval) view showing the right atrial mass lesion just adjacent to inferior vena caval drainage into right atrium. movie6.avi Video file 6. Transesophageal echocardiographic 3-dimensional bicaval view of right atrial thrombus. movie7.avi Video file 7. Transesophageal echocardiographic en-face view of right atrial thrombus. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6743321","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":464201761,"identity":"c79a7eb0-da04-4119-93b5-569b1da8e01e","order_by":0,"name":"JAIDEEP DEY","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDCCAwwGDAwGNvX97A1AnoEFsVoK0hhn9hwAaZEgVsuHw4wbbiSAuERo4bt9eONjHoPDzJIzn1/d8KNAgoG/vTsBrxbJc2nFxjwG6Wz80jllN3uADpM4c3YDXi0GZ3jMpHkMrHkkZ+ek3eABajGQyCWoxfw3jwGzhMHNM2k3/xCpxYyZx8DZwOAG+7HbRNkieYatWHKOQVqCZE8O220ZAwkegn7hO8O88cObPzYJ/OzHn90EMuT423vxawEBJh4wxWMAJgkqBwHGH2CK/QFRqkfBKBgFo2DkAQAOz0hYe14ClAAAAABJRU5ErkJggg==","orcid":"","institution":"BLK-MAX SUPERSPECIALITY HOSPITAL","correspondingAuthor":true,"prefix":"","firstName":"JAIDEEP","middleName":"","lastName":"DEY","suffix":""},{"id":464201762,"identity":"da5444cd-be47-4860-a9eb-480599173bab","order_by":1,"name":"AMITA GARG","email":"","orcid":"","institution":"BLK-MAX SUPERSPECIALITY HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"AMITA","middleName":"","lastName":"GARG","suffix":""},{"id":464201763,"identity":"7a2e81ba-09ac-442c-b840-46cd826a1d32","order_by":2,"name":"ARIF MUSTAQUEEM","email":"","orcid":"","institution":"Max Super Speciality Hospital","correspondingAuthor":false,"prefix":"","firstName":"ARIF","middleName":"","lastName":"MUSTAQUEEM","suffix":""},{"id":464201764,"identity":"c7dadba8-4007-435e-a34d-1b152fa7d8f4","order_by":3,"name":"MAN MOHAN MEHNDIRATTA","email":"","orcid":"","institution":"BLK-MAX SUPERSPECIALITY HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"MAN","middleName":"MOHAN","lastName":"MEHNDIRATTA","suffix":""},{"id":464201765,"identity":"091b1f81-adf3-4857-8643-ee2db497d7e6","order_by":4,"name":"SAMEER SHRIVASTAVA","email":"","orcid":"","institution":"Max Super Speciality Hospital","correspondingAuthor":false,"prefix":"","firstName":"SAMEER","middleName":"","lastName":"SHRIVASTAVA","suffix":""}],"badges":[],"createdAt":"2025-05-25 11:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6743321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6743321/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83838356,"identity":"bd19c55c-3d03-4490-b0e9-f63af7d6c5ec","added_by":"auto","created_at":"2025-06-03 13:38:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1131020,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A-C),\u003c/strong\u003eMRI brain demonstrating hyperintensities in right caudate nucleus and right cerebellar hemisphere (red and black arrows) consistent with acute ischemic infarction. Encephalomalacic gliotic changes in right parietal lobe (white star in figure A) consistent with previous ischemic stroke.\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic resonance imaging.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/a0ab3dd3aa48ab8ce721fc29.png"},{"id":83838014,"identity":"16bca729-b87e-4518-bfcc-8d9986f329f7","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":852674,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA,\u003c/strong\u003eECG showing normal sinus rhythm with no significant ST/T changes; \u003cstrong\u003eB, \u003c/strong\u003eChest roentgenogram showing no significant abnormality with central venous catheter line in place (red arrow).\u003c/p\u003e\n\u003cp\u003eECG: Electrocardiogram.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/da8d6b3faba979ac04bb55f3.png"},{"id":83838016,"identity":"8345637d-73c0-45c0-8284-519f7d467b08","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":520842,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-C,\u003c/strong\u003eTTE images demonstrating RA mass lesion at presentation (arrow and black star) in proximity to interatrial septum and IVC opening into RA (white star) in apical 4 chamber, short axis and subcostal views respectively; \u003cstrong\u003eD-F,\u003c/strong\u003eRepeat TTE images at 3 weeks post presentation.\u003c/p\u003e\n\u003cp\u003eAoV: Aortic valve; IVC: Inferior vena cava; LA: Left atrium; RA: Right atrium; TTE: Transthoracic echocardiography.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/b389c9f1f5c6a0b88c139586.png"},{"id":83838021,"identity":"61578945-1167-4f56-9ee2-734c524f89ae","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":566713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-C,\u003c/strong\u003e2D and 3D TEE imaging showing typical appearance of the right atrial thrombus on long axis and bicaval views at presentation (arrows and red star); \u003cstrong\u003eD-F,\u003c/strong\u003eTEE imaging at 3 weeks; \u003cstrong\u003eG-I,\u003c/strong\u003e TEE imaging at 4 weeks revealed persistence of thrombus with a reduction in bulk and friability.\u003c/p\u003e\n\u003cp\u003e2D: 2-dimensional; 3D: 3-dimensional; TEE: Transesophageal echocardiography.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/9261ae35a435aba3dbc893e4.png"},{"id":83839164,"identity":"f433e9c1-a6f4-4367-bf40-589294865b1c","added_by":"auto","created_at":"2025-06-03 13:46:00","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":599118,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-C, \u003c/strong\u003eCMR images at presentation demonstrating low signal shadowing in right atrium and partially extending into inferior vena cava consistent with thrombus (red stars); \u003cstrong\u003eD-F,\u003c/strong\u003e An area of delayed gadolinium enhancement visible on posterolateral wall of left ventricle at a subepicardial location (arrows) consistent with myocardial injury.\u003c/p\u003e\n\u003cp\u003eCMR: Cardiac magnetic resonance imaging.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/e1087ddfc02e00170dcba2cd.png"},{"id":105566342,"identity":"211ff8a4-9038-403c-a7a6-a7838c741a99","added_by":"auto","created_at":"2026-03-27 12:56:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4748173,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/1c99c6c6-6dab-40e3-9233-7cf1421111a2.pdf"},{"id":83839163,"identity":"149300d7-a1f7-46cc-8307-668ad960d3ee","added_by":"auto","created_at":"2025-06-03 13:46:00","extension":"avi","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":621166,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eSUPPLEMENTARY VIDEO FILES LEGENDS\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVideo file 1.\u003c/strong\u003e Transthoracic echocardiography (short axis) view depicting the right atrial mass lesion.\u003c/p\u003e","description":"","filename":"movie1.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/96e038e4a00456745843579a.avi"},{"id":83838357,"identity":"deb49811-a603-42db-9cf8-42ef3f960d8e","added_by":"auto","created_at":"2025-06-03 13:38:00","extension":"avi","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":611568,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 2.\u003c/strong\u003e Transthoracic echocardiography (apical 4 chamber) view depicting the right atrial mass lesion.\u003c/p\u003e","description":"","filename":"movie2.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/d23603b24914db490645629e.avi"},{"id":83838018,"identity":"86edaee3-e909-4bdf-813b-1abffd942f0c","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"avi","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":661012,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 3.\u003c/strong\u003e Transthoracic echocardiography (subcostal) view depicting the right atrial mass lesion in close proximity to inferior vena caval drainage into right atrium.\u003c/p\u003e","description":"","filename":"movie3.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/0ecbc6b5d3459d6d538e7ce9.avi"},{"id":83838020,"identity":"5e065783-cd2a-47e8-b764-2c75aa15f6fa","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"avi","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":388702,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 4.\u003c/strong\u003e Transesophageal echocardiography (0-degree long axis) view showing the right atrial mass lesion in a linear claw like configuration.\u003c/p\u003e","description":"","filename":"movie4.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/e1934539204ec566fe9e51c0.avi"},{"id":83838022,"identity":"ab90cb7f-788e-4de0-8ef4-a670ae801774","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"avi","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":756770,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 5.\u003c/strong\u003e Transesophageal echocardiography (bicaval) view showing the right atrial mass lesion just adjacent to inferior vena caval drainage into right atrium.\u003c/p\u003e","description":"","filename":"movie5.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/9404c90618fed087e04d91cf.avi"},{"id":83838024,"identity":"94734d13-7560-4f60-8414-efaa6d021cbe","added_by":"auto","created_at":"2025-06-03 13:30:00","extension":"avi","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":232728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 6.\u003c/strong\u003e Transesophageal echocardiographic 3-dimensional bicaval view of right atrial thrombus.\u003c/p\u003e","description":"","filename":"movie6.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/5cf22a011d864a87b0f6ca14.avi"},{"id":83838025,"identity":"a4d4ae0f-48b0-462f-9622-94b4677f2907","added_by":"auto","created_at":"2025-06-03 13:30:01","extension":"avi","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":46600,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo file 7.\u003c/strong\u003e Transesophageal echocardiographic en-face view of right atrial thrombus.\u003c/p\u003e","description":"","filename":"movie7.avi","url":"https://assets-eu.researchsquare.com/files/rs-6743321/v1/983429e06a3f9653c8ea1ff6.avi"}],"financialInterests":"No competing interests reported.","formattedTitle":"Myocarditis and right atrial thrombus in a patient with Thrombotic thrombocytopenic purpura- CASE REPORT","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThrombotic thrombocytopenic purpura (TTP) is a type of thrombotic microangiopathy (TMA) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is a rare disease, with reported annual incidence between 1.5-6 cases per million adults [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The classic clinical pentad of TTP (fever, neurological manifestations, thrombocytopenia, microangiopathic hemolytic anemia and renal failure) is seen in only 7\u0026ndash;10% of patients, while cardiac involvement is noted in up to 25% of patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCardiac involvement in TTP is manifested mainly in the form of microvascular thrombosis associated myocardial injury. We hereby report about an unusual presentation of a young TTP patient with myocarditis and right atrial thrombus but without cardiac symptoms.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 35-year-old male patient presented to our hospital with 1-day history of sudden onset dizziness, dysphasia, blurring of vision in right eye and deviation of angle of mouth to the left side. His past medical history was significant for obesity and hypertension. He had had a previous episode of ischemic stroke 5 months prior to the current presentation. At that time, he was diagnosed with right middle cerebral artery (MCA) territory infarction and had been thrombolysed with Alteplase at another institution. His clinical course was complicated by development of intraparenchymal hemorrhage in right parietal lobe and subarachnoid hemorrhage along bilateral frontal lobes. He was managed conservatively with medical therapy and had an uneventful recovery till the present admission. Unfortunately, previous clinical records were not available with the patient.\u003c/p\u003e \u003cp\u003eHe had no history of substance abuse or any significant family history of atherosclerotic cardiovascular disease. His current medications included- aspirin, clopidogrel, rosuvastatin, olmesartan, divalproex sodium, lacosamide, flunarizine, naproxen, domperidone, escitalopram and clonazepam.\u003c/p\u003e \u003cp\u003eAt presentation, patient was afebrile, conscious, oriented and obeying verbal commands. His heart rate was 98/minute, regular with a blood pressure of 120/70 mmHg. General physical examination was significant for presence of pallor. Nervous system examination revealed presence of deviation of angle of mouth to the left side and cerebellar signs (dysarthria). No gross motor or sensory deficits were noted.\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI) of the brain revealed, multiple areas of altered signal intensity in right caudate nucleus and right cerebellar hemisphere appearing hyperintense on diffusion weighted imaging (DWI), suggestive of acute infarct (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Small foci of DWI hyperintensities were noted in right parietal lobe, consistent with subacute infarction. Magnetic resonance angiography did not reveal any flow limiting stenosis in bilateral carotid and vertebral arteries.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe hematological and blood chemistry investigations are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Complete blood count showed severe anemia (hemoglobin- 5.7 gm/dl), leukocytosis (12.8 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l) with a leftward shift and severe thrombocytopenia (platelet count- 8.0 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l). Peripheral blood smear showed a dimorphic picture with numerous schistocytes (6.0%), nucleated red blood cells, polychromatophils and tear drop cells. Marked thrombocytopenia and neutrophilic leukocytosis were also noted. Reticulocyte count (14.6%) and serum lactate dehydrogenase (LDH-1059.3 U/l) were increased, while serum haptoglobin was markedly reduced (\u0026lt;\u0026thinsp;30.0 mg/dl). Hepatic and renal function tests were normal. Infectious disease screening, blood and urine cultures, viral markers, autoimmune markers and inherited prothrombotic state screening tests were negative. A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13) activity in blood was almost undetectable (\u0026lt;\u0026thinsp;0.2%, biological reference interval- 60.6-130.6%). High-sensitive troponin I was raised (546.0 pg/ml, biological reference interval- \u0026lt;34.2 pg/ml).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHematological and biochemical parameters of the patient at presentation and during course of therapy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOn admission\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDay 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDay 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDay 5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDay 6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDay 7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDay 8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAt 3 weeks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eAt 4 weeks\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (gm/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacked cell volume (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal leukocyte count (x10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet count (x10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e119.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e155.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e164.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e192.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e243.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e160.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e228.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReticulocyte count (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactate dehydrogenase (U/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1059.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e259.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaptoglobin (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood urea (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated glomerular filtration rate (ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilirubin (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003cp\u003e(Direct- 0.3, Indirect- 1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGOT (U/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGPT (U/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP (U/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGGT (U/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADAMTS13 activity (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh-sensitive Troponin I (pg/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e546.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eADAMTS13- A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eALP- Alkaline phosphatase\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eGGT- Gamma-glutamyl transferase\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eSGOT- Serum glutamic-oxaloacetic transaminase\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eSGPT- Serum glutamate-pyruvate transaminase\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe electrocardiogram (ECG) at presentation showed normal sinus rhythm with no significant ST/T changes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Chest roentgenogram demonstrated no significant abnormality with central venous catheter (CVC) line visualized in-situ (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Ultrasonography of abdomen was significant for grade I fatty liver with no other abnormality detected.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCardiac imaging studies\u003c/h2\u003e \u003cp\u003eTransthoracic echocardiography (TTE) revealed, an echogenic, 2.8 x 1.8 cms sized mobile, lobulated right atrial (RA) mass, in proximity to superior portion of interatrial septum. A likelihood of thrombus/neoplastic mass was considered (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, videos 1\u0026ndash;3). RA was mildly dilated. Mild 2\u0026thinsp;+\u0026thinsp;tricuspid regurgitation was noted with an estimated pulmonary artery systolic pressure of 40 mmHg.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere were no left ventricular (LV) regional wall motion abnormalities and LV ejection fraction was 55%. Grade I diastolic dysfunction was noted. Cardiac valves were morphologically normal. There was no pericardial pathology.\u003c/p\u003e \u003cp\u003eTransesophageal echocardiography (TEE) confirmed the presence of a mobile RA mass with point of attachment at the inferior vena cava (IVC) junction into RA with protrusion into RA cavity (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA-C, videos 4\u0026ndash;7). The mass had a claw-like shape with lobulations at margins. Size of the mass was 3.9 x 2.1 cms. The appearance and location pointed towards the provisional diagnosis of thrombus. No other mass lesion was noted in any other cardiac chamber.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCardiac MRI (CMR) showed a low signal intensity lesion in RA, close to IVC opening and partially extending into it, with no contrast enhancement, suggestive of thrombus (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA-C). A non-specific delayed gadolinium enhanced area (size 2.1 x 0.9 cms) was noted in posterolateral LV in subepicardial location (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eD-F). There were no myocardial perfusion deficits or wall motion abnormalities detected.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA whole-body positron emission tomography/computed tomography (PET/CT) scanning did not reveal any metabolically active lesion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical course\u003c/h3\u003e\n\u003cp\u003eIn view of a young patient presenting with recurrent ischemic stroke, a prothrombotic state was considered. Clinical presentation along with hematological and biochemical results was suggestive of TMA. An almost undetectable blood level of ADAMTS13, narrowed down the diagnosis towards TTP.\u003c/p\u003e \u003cp\u003ePatient was started on plasmapheresis (PEX) in consultation with the hematology team. Oral corticosteroid (Prednisolone) was thereafter commenced. Rituximab (anti-CD20 monoclonal antibody) therapy was also initiated. He had gradual improvement in hematological and biochemical parameters during 5 sessions of PEX and 4 cycles of rituximab infusions over the 4-week treatment duration (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Platelet counts and serum LDH levels normalized over the course of therapy. There were no subsequent thrombotic episodes. Aspirin was initiated once platelet counts improved to \u0026gt;\u0026thinsp;50 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l. A repeat TEE after 3- and 4-weeks post presentation showed persistence of the RA thrombus along with a distinct reduction in its volume and friability (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD-I). The patient is presently in clinical remission. He is on regular follow-up and planned for further management in accordance with multi-speciality consultation.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe report the case of a young male patient with TTP who presented with recurrent ischemic strokes along with cardiac involvement. TTP manifests due to an inherited or acquired deficiency of ADAMTS13. ADAMTS13 is a metalloprotease which cleaves large multimers of von Willebrand factor (VWf) under high shear stress, thereby preventing platelet aggregation and thrombosis. ADAMTS13 deficiency leads to accumulation of large multimers of VWf, resulting in uncontrolled platelet adhesion and aggregation with subsequent intravascular microthrombosis [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe unique feature in our patient was that, despite presenting with neurological symptoms, he had concomitant subclinical cardiac involvement associated with both microvascular (focal myocarditis) and macrovascular thrombosis (RA mass). The PLASMIC score (Platelet count, hemolysis, active cancer, solid organ or stem cell transplant, international normalized ratio and creatinine), which is an easily calculable risk score to predict severe ADAMTS13 deficiency was 6, indicating high risk of severe deficiency which was subsequently confirmed on lab testing [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCardiac involvement in TTP may present with troponin elevation, ECG abnormalities, heart failure, arrhythmias, cardiogenic shock or sudden cardiac death. Occasionally, presentation may be subclinical. Cardiac manifestations may be prominent in severe forms of TTP and can herald an aggressive disease course with poor prognosis. In a study involving 98 critically ill patients with severe TTP, cardiac involvement was noted in 91% of the patients [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among these patients, troponin elevation was noted as the most common presentation (72%) while isolated troponin elevation was seen in 20% of patients [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Myocarditis can develop in TTP due to thrombus formation in the microvasculature [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. Though there were no significant ECG changes in our patient, an elevated troponin level along with CMR evidence of myocarditis indicated myocardial injury.\u003c/p\u003e\n\u003cp\u003eRA thrombus in our case is an unusual finding considering the backdrop of TTP. Although macrovascular thrombosis, specifically deep vein thrombosis (DVT) has been reported in TTP, RA thrombus is distinctly uncommon [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. In a recent comprehensive review of TTP patients over a 12-year period between 2010\u0026ndash;2022, involving 221 observational studies, there were no reported cases with RA thrombosis [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. A literature search in \u003cem\u003ePubmed\u0026reg;\u003c/em\u003e as of April 2025 did not return any results pertaining to RA thrombus in TTP patients. Ours is probably the first reported case with this presentation. CVC line insertion could have predisposed to catheter associated DVT with subsequent progression into right atrium. In a retrospective study involving 55 patients of TMA admitted in intensive care over a 6-year period, 21 patients had DVT, of which 13 patients had indwelling CVC in-situ [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Factors associated with DVT included- undetectable ADAMTS13 activity level, cardiac involvement and TMA disease flare-up. Particularly, TTP associated ADAMTS13 deficiency and patients with cardiac manifestations of TMA were more susceptible to DVT [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. As these patients frequently require CVC access, careful monitoring for signs or symptoms of DVT must be ensured including venous doppler studies whenever indicated.\u003c/p\u003e\n\u003cp\u003eIn hindsight, most likely the first episode of stroke in our patient was precipitated by TTP. Misdiagnosis of TTP, particularly during the initial presentation, may occur in up to 20% of patients [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. In a retrospective study involving 423 patients of acquired TTP (diagnosed over a 14 year period), the following clinical characteristics were associated with misdiagnosis of TTP- delayed time to clinical diagnosis, female gender, history of autoimmune disorder, organ involvement before TTP diagnosis, a higher hemoglobin level, low or undetectable schistocytes, positive direct antiglobulin test, acute kidney injury stage 2 and a positive antinuclear antibody (ANA) test [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePEX along with oral corticosteroids and rituximab therapy showed a sustained hematological improvement in our patient (Tables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e,\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Anticoagulation therapy was contemplated on improvement in platelet counts, however, due to recent history of intracranial hemorrhage, this was immediately not considered, after discussion between the neurology and hematology teams. Low dose aspirin was initiated once platelet counts increased to \u0026gt;\u0026thinsp;50 x 10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l in accordance with current guidelines [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTimeline of patient events: from presentation till achievement of disease remission.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTimeline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEvents\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 months prior to current admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIschemic stroke thrombolysed with alteplase; associated with subsequent intracranial hemorrhage (medically managed)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresented with new onset ischemic stroke associated with severe thrombocytopenia and severe hemolytic anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInvestigations reveal significantly reduced ADAMTS13 activity level in blood, elevated cardiac troponin and right atrial mass lesion (thrombus)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitiation of Plasma exchange therapy (continued for 5 days), corticosteroids (Prednisolone) initiated on completion of plasma exchange\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelet levels normalized and serum LDH levels reduced by 76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitiation of weekly Rituximab therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5th week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompletion of 4 weeks of Rituximab therapy\u003c/p\u003e\n \u003cp\u003eOn tapering doses of oral corticosteroid therapy\u003c/p\u003e\n \u003cp\u003ePatient presently in clinical remission\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eCardiac involvement in TTP has important significance in patient management. As presentation may be asymptomatic, ECG, troponin levels and TTE must be performed in all suspected cases as soon as possible. An elevated cardiac troponin level confers a higher risk of mortality and treatment refractoriness [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. Clinical deterioration during the disease course warrants immediate reassessment for cardiac complications. Clinical, hematological and cardiology follow-up must be ensured in these patients in view of worse prognosis and risk of adverse cardiac events during the disease course.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCardiovascular involvement is common in TTP with asymptomatic presentation and isolated cardiac troponin elevation is most frequently noted. Prompt cardiovascular assessment is indicated on presumptive diagnosis of TTP. Though microvascular thrombosis is the usual pathology, cardiac macrovascular thrombosis may also develop. In view of worsened prognosis, such patients require a more focused and multi-modality management protocol to ensure adequate treatment response.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eTTP- Thrombotic thrombocytopenic purpura\u003c/li\u003e\n \u003cli\u003eTMA- Thrombotic microangiopathy\u003c/li\u003e\n \u003cli\u003eMCA- Middle cerebral artery\u003c/li\u003e\n \u003cli\u003eMRI- Magnetic resonance imaging\u003c/li\u003e\n \u003cli\u003eDWI- Diffusion weighted imaging\u003c/li\u003e\n \u003cli\u003eLDH- Lactate dehydrogenase\u003c/li\u003e\n \u003cli\u003eECG- Electrocardiogram\u003c/li\u003e\n \u003cli\u003eADAMTS13- A disintegrin and metalloproteinase with thrombospondin type 1 motif, \u0026nbsp;member 13\u003c/li\u003e\n \u003cli\u003eCVC- Central venous catheter\u003c/li\u003e\n \u003cli\u003eTTE- Transthoracic echocardiography\u003c/li\u003e\n \u003cli\u003eRA- Right atrium\u003c/li\u003e\n \u003cli\u003eLV- Left ventricle\u003c/li\u003e\n \u003cli\u003eTEE- Transesophageal echocardiography\u003c/li\u003e\n \u003cli\u003eIVC- Inferior vena cava\u003c/li\u003e\n \u003cli\u003eCMR- Cardiac MRI\u003c/li\u003e\n \u003cli\u003ePET/CT- Positron emission tomography/computed tomography\u003c/li\u003e\n \u003cli\u003ePEX- Plasmapheresis\u003c/li\u003e\n \u003cli\u003eVWf- von Willebrand factor\u003c/li\u003e\n \u003cli\u003ePLASMIC- Platelet count, hemolysis, active cancer, solid organ or stem cell transplant, international normalized ratio and creatinine\u003c/li\u003e\n \u003cli\u003eDVT- Deep vein thrombosis\u003c/li\u003e\n \u003cli\u003eANA- Antinuclear antibody\u003c/li\u003e\n \u003cli\u003eALP- Alkaline phosphatase\u003c/li\u003e\n \u003cli\u003eGGT- Gamma-glutamyl transferase\u003c/li\u003e\n \u003cli\u003eSGOT- Serum glutamic-oxaloacetic transaminase\u003c/li\u003e\n \u003cli\u003eSGPT- Serum glutamate-pyruvate transaminase\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eThe authors declare that they have not received funding from any source with respect to the preparation of this manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eThe patient provided proper informed consent to participate in the study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eThe patient has given informed consent for the case details and any associated medical images to be published in this case report.\u003c/li\u003e\n\u003c/ul\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConcept and design- SS, AM, JD; Recording and interpretation of imaging data- AG, JD; Patient care, lab investigation analyses- MM; Manuscript writing- JD, AG; All authors provided final approval of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our heartfelt gratitude to Dr. T. S. Kler (Chairman \u0026amp; Head of Department Cardiology), faculty and staff of the Department of Radiology and all the support staff in Non-invasive Cardiology lab BLK-Max Super Speciality Hospital, New Delhi, for their assistance and support in preparing this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAddad, V. V., Palma, L. M. P., Vaisbich M. H., et al. (2023). A comprehensive model for assessing and classifying patients with thrombotic microangiopathy: the TMA-INSIGHT score. \u003cem\u003eThromb J\u003c/em\u003e, 21(1), 119. https://doi.org/10.1186/s12959-023-00564-6.\u003c/li\u003e\n\u003cli\u003eSukumar, S., L\u0026auml;mmle, B., Cataland, S. R. (2021). Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. \u003cem\u003eJ Clin Med\u003c/em\u003e, 10(3), 536. https://doi.org/10.3390/jcm10030536.\u003c/li\u003e\n\u003cli\u003eCilla, N., Dallemagne, J., Vanhove, M., et al. (2020). Delayed Thrombotic Complications in a Thrombotic Thrombocytopenic Purpura Patient Treated With Caplacizumab. \u003cem\u003eJ Hematol\u003c/em\u003e, 9(3), 84\u0026ndash;88. https://doi.org/10.14740/jh614.\u003c/li\u003e\n\u003cli\u003eVyas, A., Isaac, S., Kaur, D., et al. (2023). Role of the PLASMIC Score in the Management of Thrombotic Thrombocytopenic Purpura. \u003cem\u003eCureus\u003c/em\u003e, 15(3), e36188. https://doi.org/10.7759/cureus.36188.\u003c/li\u003e\n\u003cli\u003eFourmont, A. M., Zafrani, L., Mariotte, E., et al. (2018). The clinical features of cardiac involvement in patients with severe thrombotic thrombocytopenic purpura. \u003cem\u003eIntensive Care Med\u003c/em\u003e, 44(6), 963\u0026ndash;965. https://doi.org/10.1007/s00134-018-5216-7.\u003c/li\u003e\n\u003cli\u003eWebb, J. G., Butany, J., Langer, G., et al. (1990). Myocarditis and myocardial hemorrhage associated with thrombotic thrombocytopenic purpura. \u003cem\u003eArch Intern Med\u003c/em\u003e, 150(7), 1535\u0026ndash;1537.\u003c/li\u003e\n\u003cli\u003eFodil, S., Zafrani, L. (2022). Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients. \u003cem\u003eJ Clin Med\u003c/em\u003e, 11(4), 1103. https://doi.org/10.3390/jcm11041103. \u003c/li\u003e\n\u003cli\u003eDu, P., Cristarella, T., Goyer, C., et al. (2024). A Systematic Review of the Epidemiology and Disease Burden of Congenital and Immune-Mediated Thrombotic Thrombocytopenic Purpura. \u003cem\u003eJ Blood Med\u003c/em\u003e, 15, 363\u0026ndash;386. https://doi.org/10.2147/JBM.S464365.\u003c/li\u003e\n\u003cli\u003eCamous, L., Veyradier, A., Darmon, M., et al. (2014). Macrovascular thrombosis in critically ill patients with thrombotic micro-angiopathies. \u003cem\u003eIntern Emerg Med\u003c/em\u003e, 9(3), 267\u0026ndash;272. https://doi.org/10.1007/s11739-012-0851-4.\u003c/li\u003e\n\u003cli\u003eGrall, M., Azoulay, E., Galicier, L., et al. (2017). Thrombotic thrombocytopenic purpura misdiagnosed as autoimmune cytopenia: Causes of diagnostic errors and consequence on outcome. Experience of the French thrombotic microangiopathies reference centre. \u003cem\u003eAm J Hematol\u003c/em\u003e, 92(4), 381\u0026ndash;387. https://doi.org/10.1002/ajh.24665.\u003c/li\u003e\n\u003cli\u003eScully, M., Rayment, R., Clark, A., et al. (2023). A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. \u003cem\u003eBr J Haematol\u003c/em\u003e, 203(4), 546\u0026ndash;563. https://doi.org/10.1111/bjh.19026.\u003c/li\u003e\n\u003cli\u003eMatsumoto, M., Miyakawa, Y., Kokame, K., et al, \u0026amp; For TTP group of Blood Coagulation Abnormalities Research Study Team, Research on Rare and Intractable diseases, Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan (2023). Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. \u003cem\u003eInt. J. Hematol\u003c/em\u003e, 118(5), 529\u0026ndash;546. https://doi.org/10.1007/s12185-023-03657-0.\u003c/li\u003e\n\u003cli\u003eAzoulay, E., Bauer, P. R., Mariotte, E., et al. (2019). Expert statement on the ICU management of patients with thrombotic thrombocytopenic purpura. \u003cem\u003eIntensive Care Med\u003c/em\u003e, 45(11), 1518\u0026ndash;1539. https://doi.org/10.1007/s00134-019-05736-5.\u003c/li\u003e\n\u003cli\u003eWiernek, S. L., Jiang, B., Gustafson, G. M., et al. (2018). Cardiac implications of thrombotic thrombocytopenic purpura. \u003cem\u003eWorld J Cardiol\u003c/em\u003e, 10(12), 254\u0026ndash;266. https://doi.org/10.4330/wjc.v10.i12.254.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Thrombotic thrombocytopenic purpura, Right atrial thrombus, Myocarditis, Troponin I, Plasma exchange therapy","lastPublishedDoi":"10.21203/rs.3.rs-6743321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6743321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThrombotic thrombocytopenic purpura is a very rare form of thrombotic microangiopathy with an annual incidence ranging between 1.5-6 cases per million adult individuals. Cardiac involvement in thrombotic thrombocytopenic purpura may be diagnosed in up to a quarter of these patients, often associated with an adverse prognosis. Though cardiac microvascular thrombosis is most commonly noted, macrovascular thrombosis may also occur.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e We report about a young male patient with obesity and hypertension who presented with recurrent ischemic strokes. He was found to be having severe hemolytic anemia along with severe thrombocytopenia. A diagnosis of thrombotic thrombocytopenic purpura was confirmed due to almost undetectable levels of a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 levels.\u003c/p\u003e\n\u003cp\u003eHis troponin I level was also elevated while having no cardiac symptoms. He was diagnosed with asymptomatic myocarditis along with right atrial thrombosis which was confirmed with transesophageal echocardiography and cardiac magnetic resonance imaging. This is probably the first reported case of concomitant myocarditis with intracardiac thrombosis in a patient of thrombotic thrombocytopenic purpura. Prompt initiation of plasma exchange therapy followed by corticosteroids, rituximab and aspirin led to disease remission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIntensivists and cardiologists must be aware of the varied presentations associated with thrombotic thrombocytopenic purpura. Early diagnosis and cardiac evaluation is essential for ensuring a favorable outcome in these critically ill patients.\u003c/p\u003e","manuscriptTitle":"Myocarditis and right atrial thrombus in a patient with Thrombotic thrombocytopenic purpura- CASE REPORT","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 13:29:55","doi":"10.21203/rs.3.rs-6743321/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"41b2cb09-d1a3-4edc-a8e1-83572dbc0463","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T22:54:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 13:29:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6743321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6743321","identity":"rs-6743321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}