American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

An Unusual Presentation of Thrombotic Thrombocytopenic Purpura

 

Pertinent findings at autopsy included (A) the heart showing multiple foci of subepicardial acute infarction (gross image) and (B) platelet fibrin thrombi in the coronary microvasculature (hematoxylin & eosin stain, 400×).

Pertinent findings at autopsy included (A) the heart showing multiple foci of subepicardial acute infarction (gross image) and (B) platelet fibrin thrombi in the coronary microvasculature (hematoxylin & eosin stain, 400×).

We describe a patient with sudden and severe postoperative thrombocytopenia whose diagnosis was delayed. The patient was a 58-year-old black man with diabetes mellitus type 2, hypertension, and chronic kidney disease, who presented to our institution with 4 days of abdominal pain. He had a history of remote exploratory laparotomy for an abdominal gunshot wound repair.

Assessment

His physical examination was remarkable for obesity (body mass index of 30.4 Kg/m2), abdominal distension, pain, and rebound tenderness. There were no signs of hemolysis. Vital signs included temperature of 37.4°C, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and blood pressure of 174/99 mm Hg. Laboratory studies showed a hemoglobin of 12.5 g/dL, white blood cell count of 9.4 × 109/L, platelet count of 211 × 109/L, blood urea nitrogen of 26 mg/dL, serum creatinine of 2.3 mg/dL, and troponin I of 0.025 ng/mL (reference range: <0.04 ng/mL).

A computed tomography scan of the abdomen and pelvis revealed low-grade functional obstruction with segmental small bowel thickening and nonspecific mesenteric stranding and adenopathy. The differential diagnosis included Crohn’s disease, lymphoma, and mechanical small bowel obstruction due to postsurgical adhesions. He was admitted for further management, but the location of the obstruction was inaccessible by upper or lower endoscopy.

Within 12 hours of admission, the patient underwent laparoscopic resection of a 20-cm segment of ischemic small bowel. He tolerated the procedure well. The following day, the patient was given prophylactic low-molecular-weight heparin and was noted to have mild thrombocytopenia (113 × 109/L) and a hemoglobin of 11.7 g/dL. Due to a remote possibility of heparin-induced thrombocytopenia, low-molecular-weight heparin was discontinued, and bivalirudin was initiated. His platelet count decreased to 15.7 × 109/L on postoperative day (POD) 2 and his renal function worsened during the course of hospitalization (Figure 1). One unit of apheresis platelets was transfused on POD 3 but his platelet count did not increase.

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-Yaolin Zhou, MD, Stephanie D. Reilly, MD, Radhika Gangaraju, MD, Vishnu V.B. Reddy, MD, Marisa B. Marques, MD

This article originally appeared in the August 2017 issue of The American Journal of Medicine.

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