jkra The Journal of the Korean Rheumatism Association J Korean Rheum Assoc 1226-8070 2233-4718 The Korean Rheumatism Association 10.4078/jkra.2009.16.4.296 jkra-16-296 Original Article Thrombotic Thrombocytopenic Purpura Induced by Trimethoprim-Sulfamethoxazole in a Patient with Rheumatoid Arthritis SohnJi Youn LeeKyung Ae HongYun Kyung YooWan-Hee Division of Rheumatology, Department of Internal Medicine, Chonbuk National University Medical School and The Research Institute of Clinical Medicine, Jeonju, Korea 01 2009 20 01 2009 16 4 296 200 15062009 22072009 22072009 Copyright © 2009 The Korean Rheumatism Association 2009 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract

Thromobotic thrombocytopenic purpura (TTP) is a multisystem disorder that's characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, and neurologic symptoms. TTP is associated with many diseases and several therapeutic drugs. We report here on the first Korean case of a patient with rheumatoid arthritis (RA) and who developed TTP that was associated with trimethoprim-sulfamethoxazole (TMP-SMX) in Korea. She recovered from the TTP following daily sessions of therapeutic plasma exchange (TPE) with fresh plasma replacement and glucocorticoid therapy. Awareness of the possible development of TTP in patient with RA and who is being treated with TMP-SMX is important for making the early diagnosis and administering proper treatment.

 Thrombotic thrombocytopenic purpura Rheumatoid arthritis Trimethoprim-Sulfamethoxazole Therapeutic plasma exchange Glucocorticoid References Murrin RJ Murray JA Thrombotic Thrombocytopenic Purpura: aetiology, pathophysiology and treatment Blood Rev 200620 5160 Herrington A Mahmood A Berger R Treatment options in Sulfamethoxazole Trimethoprim-induced thrombocytopenic purpura South Med J 199487 94850 Martin MG Whitlatch NL Shah B Arepally GM Thrombotic thrombocytopenic purpura induced by Thrimethoprim-Sulfamethoxazole in a Jehovah's Witness Am J Hematol 200782 67981 Kfoury Baz EM Mahfouz RA Masri AF Thrombotic Thrombocytopenic purpura in a patient with rheumatoid arthritis treated by plasmapheresis Ther Apher 19993 3146 Moschowitz E An acute fevrile pleiochromic anemia with hyaline thrombosis of the terminal arterioles and capillaries: An undescribed disease Am J Med 195213 5679 Li CH Ho CL Thrombotic thrombocytopenic purpura as the initial presentation of Pneumocystis jiroveci pneumonia in an immunocompetent patient Ann Hematol. 200786 2234 Gopal M Cohn CD McEntire MR Alperin JB Thrombotic thrombocytopenic purpura and adult onset Still's disease Am J med Sci 2009337 3736 Speth PA Boerbooms AM Holdrinet RS Van de Putte LB Meyer JW Thrombotic thrombocytopenic purpura associated with D-penicillamine treatment in rheumatoid arthritis J Rheumatol 19829 8123 Trice JM Pinals RS Plitman GI Thrombotic thrombocytopenic purpura during penicillamine therapy in rheumatoid arthritis Arch Intern Med 1983143 14878 Parker JC Barrett DA Hill C Microangiopathic hemolysis and thrombocytopenia related to penicillin drug Arch Intern Med 1971127 4747 Elliott MA Nichols WL Jr Plumhoff EA Ansell SM Dispenzieri A Gastineau DA Posttrasplantation thrombotic thrombocytopenic purpura: a single-center experience and a contemporary review Mayo Clin Proc 200378 42130 Smilack JD Trimethoprim-sulfamethoxazole Mayo Clin Proc 199974 7304 Zakarija A Bennett C Drug-induced thrombotic mic-roangiopathy Semin Thromb Hemost 200531 68190 Feiza BA Samy F Asma D Rym B Insaf M Urti-carian vasculitis A case report after Sulfamethoxazo-letrimethoprime ingestion Tunis Med 200583 7146 Kremer Hovinga JA Meyer SC Current management of thrombotic thrombocytopenic purpura Curr Opin Hematol 200815 44550 Figures

Overall, this X-ray shows an irregular ground glass appearance in both lung fields, and this aspect is prominent on the upper lung fields.

The HRCT shows consolidations and ground glass opacities in both lung fields, and this it appears with a sparing patterns at the subpleural regions.

After 4 days treatment with TMP-SMX, the X-ray shows markedly improved findings.