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The patient is a 47-year-old female with a history of coronary artery disease, hypertension, asthma, diabetes and obstructive sleep apnea who presented to an outside hospital with shortness of breath and lethargy. The patient was found to be in diabetic ketoacidosis, which was treated with an insulin drip. She also had a platelet count of 8 x 10 9 /L on initial laboratory studies. She was presumed to have immune thrombocytopenic purpura (ITP) and treated with five days of intravenous immunoglobulin (IVIG) without improvement. She was transferred to Thomas Jefferson University Hospital for further management. Initial vital signs included a temperature of 100.1 degrees Fahrenheit, pulse of 101 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 107/45 mmHg and oxygen saturation of 100% on room air. On physical exam, she was lethargic and not oriented. She had pupils that were equally round and reactive to light; her extraoccular muscles were intact. She had no lymphadenopathy. Her cardiac exam revealed a regular rate and rhythm with no murmurs. She had no crackles in her lung fields. Her abdomen was soft, non-tender, non-distended, with normal bowel sounds. Her extremities demonstrated purpuric lesions throughout, but were non-edematous. Laboratory studies showed a hemoglobin of 6.5 g/dl, white blood cell count of 13.3 x10 9 /L, and platelet count of 65 x10 9 /L. Her creatinine was 0.9 mg/dL. As there was a concern for thrombotic thrombocytopenic purpura (TTP), a peripheral blood smear was evaluated and found to have schistocytes. There was also evidence for microan-giopathic hemolytic anemia (MAHA) demonstrated by a lactate dehydrogenase (LDH) of 1451 IU/L (normal 100-200 IU/L) and a haptoglobin of 31 mg/dL (normal 16-200 mg/dL). Given the presence of a low grade fever, MAHA, thrombocytopenia, and mental status change, a diagnosis of TTP was presumed. The patient required intubation for airway protection. An apheresis catheter was placed, and urgent plasmapheresis was started. Her course was complicated by transient low blood pressures which were treated with norepinephrine infusion for two days. Her course was complicated by a spontaneous retroper-itoneal hematoma, which accounted for a further decrease in her hemoglobin and required transfusion of packed red blood cells. The patient was also treated for a multifocal pneumonia and clostridium difficile diarrhea. She also had acute renal failure which was thought to be acute tubular necrosis secondary to her transient hypotension rather than the TTP. The patient received …

Thrombotic Thrombocytopenic Purpura: A Review of the Disease Entity, its Clinical and Laboratory Features, and Management Strategies