Clinical History:
A 41-year-old woman has had headaches with blurred vision for several days. Over the past day she has developed increasing mental confusion. On admission to the hospital, she has vital signs showing temperature 37.9 C, pulse 104/minute, respirations 25/minute, and blood pressure 70/40 mmHg. She has petechial hemorrhages noted over her arms and trunk on physical examination, along with stool positive for occult blood. Her CBC showed a WBC count of 8950/microliter, hemoglobin 9.1 g/dL, hematocrit 27.2%, MCV 92 fL, RDW 19%, and platelet count 8900/microliter. The peripheral blood smear shows schistocytes. A serum electrolyte panel shows sodium 147 mmol/L, potassium 5.0 mmol/L, chloride 105 mmol/L, CO2 26 mmol/L, creatinine 2.9 mg/dL, urea nitrogen 32 mg/dL, and glucose 80 mg/dL.
Questions:
What is the most likely diagnosis? The findings are consistent with thrombotic thrombocytopenic purpura (TTP) with the pentad of neurologic abnormalities, fever, acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. This condition is most often seen in adult women, and it can have an abrupt onset.
What should you do to treat this condition? Plasmapheresis is indicated and will be about 90% effective in treating TTP.
What is contraindicated? Platelets should NOT be given. Giving platelets will just add "fuel to the fire" and the patient's condition will worsen.
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