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Washington University Experience | VASCULAR | Thrombotic Thrombocytopenic Purpura (TTP) | 3A0 Case 3 History
Case 3 History ---- The patient had a history of hypertension and noninsulin dependent diabetes. On 4/7 the patient noted dimming of vision in the left eye followed several minutes later by difficulty choosing words. Comprehension was normal, but writing was jumbled. All symptoms resolved over 1-2 hours. He was taken to a local hospital where a BP of 190/120 was measured and a left carotid bruit. Laboratory data showed a glucose of 354 and a hematocrit of 27. TIA workup included normal skull x-ray, brain scan, EEG and carotid angiograms bilaterally. Treatment was initiated with aspirin and Dipyridamole and Pavabid. Insulin Rx and antihypertensive Rx was begun. A TIA developed following angiography which also resolved. On 4/2 he developed a dead feeling in his left hand lasting 15 minutes. His cranial nerve exams showed slight flattening of the right nasolabial fold and slight dysmetria in the left upper extremity. Laboratory data included peripheral smear showed 28% nucleated RBCs anisocytosis and poikilocytosis, polychromatia, and microspherocytes, burr cells and schistocytes. Platelet count was 10K on admission and retic count was 25%. PT was 14.8 (nl 10-13 if not anticoagulated), PTT was 28 (nl 25-30 sec), and fibrinogen was 410 (nl 200-400mg/dl). Creatinine on admission was 1.4, bilirubin was 2.0, LDH was 600, and SGOT was 66. The sedimentation rate was 53 mm/hr. The patient was Coombs negative. Because of the decreased platelets and peripheral smear and the fluctuating neurologic course, the patient was felt to have TTP. Bone marrow aspirate showed marked erythroid hyperplasia and abundant megakaryocytes. The patient was placed on Dipyridamole and high dose steroids. The patient initially did well, however, on 4/25 he had an episode of confusion with an apparent fluent aphasia. He had upbeat nystagmus on upgaze and in primary position and downbeat nystagmus on lateral gaze. On attempting to walk the patient, the patient suddenly had vertigo and vomiting. He however, remained alert. On 4/26, the patient had a grand mal seizure that was symmetric with his eyes rolling up. On 4/27, he was no longer alert, but would respond to noxious stimuli with moaning, had a marked right hemiparesis, and difficulty moving his eyes to the right. Cheyne Stokes respiration and hyperventilation were noted. Exchange plasmapheresis was attempted and the patient became apneic during the procedure. Asystole was found on the cardiogram and resuscitation measures were unsuccessful.
