Abstract
Accurate and prompt diagnoses of thrombotic microangiopathy (TMA) in the emergency room (ER) and intensive care unit (ICU) setting can be challenging since its presentation involve multiple organ systems, and comorbid diseases can be deceptive for an accurate diagnosis. Here, we present the case of a patient, who upon arrival to the ER, reported severe chest pain radiating to his left shoulder, diaphoresis, headache, and nausea. Several numbers of small petechiae on the bilateral lower extremities were also found during physical examination. Laboratory data demonstrated elevated troponin levels, platelet count of 34, and hemoglobin of 8.7 g/l. Establishing a differential diagnosis between a microvascular occlusive disorder and acute coronary syndrome was imperative to reduce further clinical complications and mortality. A peripheral smear, which is an essential test in approaching the diagnosis of thrombotic thrombocytopenic purpura (TTP), was done and it identified an increased number of schistocytes. The laboratory findings narrowed the diagnosis to an immunological process, where the dysfunctional platelets caused coronary thrombosis and further intermittent coronary ischemia. In this case report, we discuss the atypical presentation of TTP, its differential diagnosis, and management in order to develop an effective treatment in the ER and ICU settings and to reduce the mortality rate.
Highlights
Thrombotic thrombocytopenic purpura (TTP) is a relatively rare disorder whose hallmarks are thrombocytopenic, microangiopathic hemolytic anemia (MAHA), and neurological dysfunction
A peripheral smear, which is an essentialtest in approaching the diagnosis of thrombotic thrombocytopenic purpura (TTP), was done and it identified an increasednumber of schistocytes
The laboratory findingsnarrowed the diagnosis to animmunological process, where the dysfunctional platelets caused coronary thrombosis and further intermittent coronary ischemia.In this case report, we discuss the atypical presentation of TTP, its differential diagnosis, and management in order to develop an effective treatment in the emergency room (ER) and intensive care unit (ICU) settings and to reduce the mortality rate
Summary
Thrombotic thrombocytopenic purpura (TTP) is a relatively rare disorder whose hallmarks are thrombocytopenic, microangiopathic hemolytic anemia (MAHA), and neurological dysfunction. Physical exam was remarkable for small petechial lesions in his lower extremities bilaterally His complete blood count analysis showed evidence of thrombocytopenia, with a platelet count of 9 x 10 9/l and anemia, with a hemoglobin count of 8.7 g/l. Troponin was mildly elevated at 0.24 ng/ml; electrocardiogram (EKG) was unremarkable At this point, based on the patient's presentation and his laboratory findings, the top differential diagnoses included acute coronary syndrome as well as an immunological reaction, such as TTP. Based on the clinical presentation and evidence present, we decided to treat the patient with a presumptive diagnosis of TTP. He received plasma exchange and after frothing for days, his platelet count returned to normal levels.
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