Abstract
Thrombotic thrombocytopenic purpura (TTP) is an autoimmune disorder characterized by thrombocytopenia, hemolytic anaemia, fluctuating neurological deficits, fever, and kidney failure. This clinical case is about a young man who presented with acute-onset right-sided paralysis, dysarthria, and central facial paralysis, suggestive of the cerebrovascular accident but finally diagnosed as TTP. In addition, the clinical presentation of TTP is discussed and some teaching points for emergency physicians are emphasized.
Keywords: thrombotic thrombocytopenic purpura, emergency department, acute ischemic stroke, dysarthria.
Report of a case
A previously healthy 36-year-old man came to our emergency department (ED) with right arm weakness, numbness on the right side of the face, and difficulty speaking, which developed an hour before the presentation. He had had a fever, cough, headache, and bleeding gums for 10 days. On examination, the patient’s blood pressure was 160/100 mm Hg, pulse 94 beats/min, respiratory rate 14 breaths/min, and temperature 38.0 ° C. Neurological examination revealed 2/5 arm weakness right, 4/5 weakness of the right leg, dysarthria and right central facial palsy. There was no stiff neck or cerebellar abnormalities.
After blood was drawn for lab tests, he underwent a cranial computed tomography (CT) scan in 30 minutes. The computed tomography did not show intracranial or subarachnoid haemorrhage or signs of ischemia. After another half hour, his neurological findings resolved. A diagnosis of transient ischemic attack was considered and admission to neurology was planned.
Laboratory test results were unexpected: white blood cell count 12,000 × 109, hemoglobin 74 g / L (7.4 g / dL), hematocrit 0.21 (21.1%), and platelet count 11,000 × 109 Urea, creatinine, electrolytes, and liver function were normal. Urinalysis was remarkable with +3 erythrocytes. Indirect bilirubin and lactate dehydrogenase levels were elevated. Intravascular hemolysis was suspected and a blood smear was requested. Three hours after presentation, the previous neurological symptoms reappeared for one hour and then gradually resolved again.
Intravascular hemolysis, thrombocytopenia, hematuria, fluctuating neurologic findings, and fever were consistent with a diagnosis of TTP. The patient was admitted and underwent emergency plasmapheresis. He did not present any neurological symptoms during the course of treatment. Complete remission was achieved on day 12 after admission and he was discharged on day 16.
Conclusion
Prompt diagnosis and treatment are necessary to decrease the risk of fatal outcomes in patients with TTP. Emergency physicians must be familiar with the clinical presentation and laboratory abnormalities of TTP in order to make an early diagnosis. In patients with fluctuating neurologic findings, thrombocytopenia, hemolytic anaemia, and fever, the diagnosis of TTP should be considered.