Opana Associated TTP-Like Illness | Teaching Points

The histologic features of thrombotic microangiopathy (TMA) associated with intravenous abuse of extended-release oxymorphone hydrochloride (Opana ER) are shown in these photomicrographs. Medium-power view of an interlobular-sized artery shows severe mucoid intimal edema and associated fractured RBCs (arrow). Adjacent glomeruli show ischemic basement membrane wrinkling. A high-power view of same biopsy specimen shows near-luminal occlusion of an interlobular-sized artery secondary to severe endothelial cell swelling and mucoid intimal edema. By electron microscopy, glomerular basement membranes showed marked subendothelial electron-lucent expansion (arrow).

Oral extended-release oxymorphone hydrochloride (Opana ER) is an opioid agonist that has undergone a tamper-resistant reformulation. A report by the CDC included 15 patients from Tennessee who presented with a TTP-like illness associated with injection of this reformulated drug.1 Kidney biopsies from patients with Opana-associated TTP-like illness show the changes demonstrated in the photomicrographs presented here, with severe arterial mucoid intimal edema and resultant glomerular ischemia.2 Kidney outcome is poor in most cases.

References:

1. Centers for Disease Control and Prevention (CDC). Thrombotic thrombocytopenic purpura (TTP)–like illness associated with intravenous opana ER abuse — Tennessee, 2012. MMWR Morb Mortal Wkly Rep. 2013; 62: 1-16.
2. Ambruzs JM, Serrell PB, Rahim N, et al. Thrombotic microangiopathy and acute kidney injury associated with intravenous abuse of an oral extended-release formulation of oxymorphone hydrochloride: kidney biopsy findings and report of 3 cases. Am J Kidney Dis 2014; 63 1022-1026