DOI: https://doi.org/10.36347/sasjm.2026.v12i10.015

Pages: 1106-1110

We report the case of a 69-year-old woman with metastatic lung adenocarcinoma who developed severe thrombotic microangiopathy (TMA) only seven days after receiving her first dose of gemcitabine. The patient had pre-existing stage 3a chronic kidney disease and previous exposure to bevacizumab, which may have increased her susceptibility to endothelial injury. She presented with profound thrombocytopenia, hemolytic anemia, severe acute kidney injury, proteinuria, and microscopic hematuria. Although the schistocyte count was below the conventional diagnostic threshold, elevated lactate dehydrogenase, markedly decreased haptoglobin, and a negative Coombs test supported the diagnosis of microangiopathic hemolysis. Thrombotic thrombocytopenic purpura was excluded by a normal ADAMTS13 activity level, while complement investigations were unremarkable. Renal biopsy confirmed TMA with characteristic glomerular and arteriolar lesions, supporting gemcitabine-induced TMA after exclusion of alternative causes. Gemcitabine was immediately and permanently discontinued, and the patient was managed with hemodialysis without plasma exchange or complement-targeted therapy, resulting in a favorable clinical and renal outcome. This case highlights the exceptionally early onset of gemcitabine-induced TMA, demonstrating that this complication can occur after the first administration and is not necessarily related to cumulative drug exposure. It also emphasizes that significant schistocytosis may be absent and should not exclude the diagnosis when other clinical and laboratory findings are suggestive. Early recognition, prompt withdrawal of gemcitabine, and appropriate supportive treatment remain essential to improving outcomes.