PAINE #PANCE Pearl – Hematology



31-year-old female, with a history of controlled SLE, presents to your office with a 2 week history of headache, weakness, dizziness, and nausea.  She also reports a new rash on her legs that is non-pruritic.  She denies any recent illnesses, sick contacts, vomiting, abdominal pain, cough, or shortness of breath.  She has been taking hydroxychlorquine for her SLE and has had little complications from this disease.


Vital Signs

BP-131/72, HR-116, RR-15, O2-100%, T-101.2 F


Physical Exam

GeneralMild distress

Skin

Image result for ttp rash

HEENT

index

NeckSupple, no LAD

PulmonaryCTA without adventitial breath sounds

CVTachycardic without M/G/R

AbdomenS/NT/ND

PV2+ throughout

Neurologic5/5 strength throughout, 2+ reflexes throughout

PsychiatricA&Ox3


Laboratory Screening

fishbones



Answer

  1. This patient has thrombotic thrombocytopenia purpura (TTP), which is a thrombotic microangioapathy caused by severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13 and small-vessel platelet-rich thrombi.  Classically it is associated with a pentad of symptoms (but current research only shows 5% of patients with all five):
    1. Hemolytic anemia
      1. Low H/H and high LDH
    2. Thrombocytopenia
      1. <150,000
    3. Neurologic symptoms
      1. Confusion, headache, focal deficits
    4. Fever
    5. Acute Kidney Injury
      1. Elevated creatinine
  2. Addition findings in this patient that support the diagnosis are:
    1. Purpuric rash from small-vessell thrombosis
    2. Scleral icterus from elevated indirect bilirubin from hemolysis
  3. Additional laboratory studies to help with the diagnosis of TTP are:
    1. Hemolysis labs
      1. Serum haptoglobin
        1. Often elevated
      2. Direct antiglobulin (Coombs) test (DAT)
        1. Often negative
    2. Fibrinogen and D-Dimer
      1. Evaluate for DIC as severely ill patient can progress to this very quickly
    3. ADAMTS13 activity and inhibitor testing
      1. Gold standard and confirmatory test of choice

 


References

  1. George JN, Nester CM. Syndromes of thrombotic microangiopathy. The New England Journal of Medicine. 2014;371(7):654-66. [pubmed]
  2. George JN. How I treat patients with thrombotic thrombocytopenic purpura: 2010. Blood. 2010;116(20):4060-9.  [pubmed]
  3. Griffin D, Al-Nouri ZL, Muthurajah D. First symptoms in patients with thrombotic thrombocytopenic purpura: what are they and when do they occur? Transfusion. 2013;53(1):235-7.  [pubmed]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s