Same Disease, Different Service

1Tulane University, New Orleans, LA
2Tulane University, New Orleans, LA

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 221

Case Presentation:

An 18‐year‐old woman presented with 4 weeks of constant, painless vaginal bleeding. She had had a normal spontaneous vaginal delivery that required anepisiotomy 4 months prior to presentation. She noted associated nausea, vomiting, dyspnea, and 1 episode of loss of consciousness accompanied by left‐sided weakness. Her blood pressure on admission was 86/54 mm Hg. her pulse was 106 bpm, and her temperature was 98.3°F. The physical examination was otherwise normal. Her hemoglobin was 5.8 g/dL, and the wtiite blood cell count was 10,000 cells/μL; her platelet count was 9000 cells/μL. Her pregnancy test was negative. The peripheral smear showed schistocytes; the INR was normal, as was her renal function. LDH was 1250, fibrinogen was 609 IU, and D‐dimer was 5201 IU. She was started on antibiotics and transfused multiple units of PRBCs and platelets. She had an ultrasound of the pelvis that excluded retained placental products. On the second hospital day, she began having seizures. With this symptom, thrombotic Thrombocytopenic purpura (TTP) was suspected. Plasmapheresis was initiated, resulting in an increased platelet count from 4000 To 21,000. An ADAMTS‐13 returned as less than 5. She was also started on vincristine, glucocorticoids, and rituximab. She was discharged on hospital day 40 with a platelet count of 239,000 and a prednisone taper.

Discussion:

Anemia and thrombocytopenia are commonly encountered by The hospitalist. Recognizing the clinical presentation of TTP is critical, as a delay in diagnosis can result in irreversible end‐organ damage and death. Although TTP is classically defined by a pentad of anemia, thrombocytopenia, fever, neurologic symptoms, and renal failure, it is important that the hospitalist recognize that few cases present with all 5 criteria. Like in our patient, early clinical suspicion and management of TTP is critical, as early intervention decreases mortality from 90% to 10%. As hospitalists expand their clinical role to include the comanagement of obstetrics patients, it is important to consider TTP as a cause of postpartum hemorrhage. The more common causes of postpartum hemorrhage include HELLP syndrome, preeclampsia, eclampsia, and retained placental products. These conditions require time‐consuming imaging studies, blood tests and cultures, delaying a diagnosis and initiation of treatment should TTP be the cause. In addition, these syndromes can present with thrombocylopenia, neurologic symptoms, renal insufficiency, and hemolytic anemias, which make them difficult to distinguish from TTP.

Conclusions:

Although the ADAMTS‐13 test is confirmatory, the result is rarely available in a timely fashion; waiting for test results causes unacceptable delays in treatment. The hospitalist should suspect TTP in patients with postpartum hemorrhage, initiating early and aggressive therapy once the most common causes of postpartum hemorrhage have been excluded.

Author Disclosure:

C. Blanton, none; A. Small, none.

To cite this abstract:

Blanton C, Small A. Same Disease, Different Service. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 221. https://www.shmabstracts.com/abstract/same-disease-different-service/. Accessed December 10, 2018.

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