J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 15, Number 10, October 2024, pages 272-277

Thrombotic Microangiopathy After Long-Lasting Treatment by Gemcitabine: Description, Evolution and Treatment of a Rare Case

Figure 1. Renal biopsies in TMA due to gemcitabine. (Left column) Immunohistochemistry with Masson trichrome showing (A) ischemic glomerulus with flocculus retraction, (B) doubling of glomerular basement membrane, (C) glomerular mesangiolysis. (Right column) Immunofluorescence showing positive staining for IgM, C3, and IgA.

**Table 1.** Cumulative Dose and Median Duration of Gemcitabine Treatment at Time of Thrombotic Microangiopathy Development, Review of the Literature
Study	Patients	Gemcitabine administration
*Pooled cases of gemcitabine-induced and mitomycin C-induced thrombotic microangiopathy. M: male; F: female.
Our case	F, 55 years	37	48
Fung et al, 1999 [3]	12	18.2 (2.45 - 40.2)	5.8 (3.8 - 13.1)
Flombaum et al, 1999 [18]	3	N/A	12 (12 - 17)
Glezerman et al, 2009 [5]	29	22 (4 - 81)	7.5 (2 - 34)
Al Ustwani et al, 2014 [7]	4	21.2	11 (3 - 39.5)
Leal et al, 2014 [20]	3	12.5	1 (0.5 - 6)
Ritchie et al, 2017 [19]	3	21.5 (8 - 22.1)	4.5 (1.5 - 4.5)
Turner et al, 2016 [16]	2	N/A	3
Gosain et al, 2017 [15]	2	N/A	7 (6.3 - 8.4)
Daviet et al, 2019 [4]	120	12.9 (6.3 - 17.6)	7 (4 - 8.5)
Grall et al, 2021 [8]	12	31.2 (9 - 48)	6 (1.7 - 16)
Takigawa et al, 2023 [6]	18	21 (2.8 - 53.6)	9 (0.5 - 37)
Klomjit et al, 2023 [21]	379*	N/A	5.2 (3 - 8.2)
Walter et al, 2002 [17]	F, 45 years	70	18
Gore et al, 2009 [9]	F, 46 years	N/A	3
Starck et al, 2013 [14]	M, 45 years	N/A	3.5
Facchini et al, 2017 [10]	M, 3 years	N/A	3
Rogier et al, 2016 [12]	F, 68 years	7	Around 2
Krishnappa et al, 2018 [11]	F, 64 years	N/A	3
Martin et al, 2019 [13]	M, 56 years	25.5	3.5

Table 1. Cumulative Dose and Median Duration of Gemcitabine Treatment at Time of Thrombotic Microangiopathy Development, Review of the Literature

Study

Patients

Gemcitabine administration

Cumulative dose (g/m²)

Median duration (months)

*Pooled cases of gemcitabine-induced and mitomycin C-induced thrombotic microangiopathy. M: male; F: female.

Our case

F, 55 years

Fung et al, 1999 [3]

18.2 (2.45 - 40.2)

5.8 (3.8 - 13.1)

Flombaum et al, 1999 [18]

N/A

12 (12 - 17)

Glezerman et al, 2009 [5]

22 (4 - 81)

7.5 (2 - 34)

Al Ustwani et al, 2014 [7]

21.2

11 (3 - 39.5)

Leal et al, 2014 [20]

12.5

1 (0.5 - 6)

Ritchie et al, 2017 [19]

21.5 (8 - 22.1)

4.5 (1.5 - 4.5)

Turner et al, 2016 [16]

N/A

Gosain et al, 2017 [15]

N/A

7 (6.3 - 8.4)

Daviet et al, 2019 [4]

120

12.9 (6.3 - 17.6)

7 (4 - 8.5)

Grall et al, 2021 [8]

31.2 (9 - 48)

6 (1.7 - 16)

Takigawa et al, 2023 [6]

21 (2.8 - 53.6)

9 (0.5 - 37)

Klomjit et al, 2023 [21]

379*

N/A

5.2 (3 - 8.2)

Walter et al, 2002 [17]

F, 45 years

Gore et al, 2009 [9]

F, 46 years

N/A

Starck et al, 2013 [14]

M, 45 years

N/A

3.5

Facchini et al, 2017 [10]

M, 3 years

N/A

Rogier et al, 2016 [12]

F, 68 years

Around 2

Krishnappa et al, 2018 [11]

F, 64 years

N/A

Martin et al, 2019 [13]

M, 56 years

25.5

3.5

**Table 2.** Summary of Immunofluorescence Staining of Complement in Renal Biopsy of G-TMA
Study	Patients	Immunofluorescence staining
G-TMA: thrombotic microangiopathy under gemcitabine; M: male; F: female.
Our case	F, 55 years	IgM++, IgA++, C3+
Murugapandian et al, 2015 [23]	F, 74 years	Negative
Krishnappa et al, 2018 [11]	F, 64 years	C3++
Burns et al, 2020 [24]	M, 39 years	IgM++, C3++, C1q+
Grall et al, 2021 [25]	12	C5b9+++ in tubule, glomerulus and capillary wall of all patients

Table 2. Summary of Immunofluorescence Staining of Complement in Renal Biopsy of G-TMA

Study

Patients

Immunofluorescence staining

G-TMA: thrombotic microangiopathy under gemcitabine; M: male; F: female.

Our case

F, 55 years

IgM++, IgA++, C3+

Murugapandian et al, 2015 [23]

F, 74 years

Negative

Krishnappa et al, 2018 [11]

F, 64 years

C3++

Burns et al, 2020 [24]

M, 39 years

IgM++, C3++, C1q+

Grall et al, 2021 [25]

C5b9+++ in tubule, glomerulus and capillary wall of all patients