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Endgames Case Review

A young woman with fever and loss of consciousness

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4363 (Published 06 December 2018) Cite this as: BMJ 2018;363:k4363
  1. Selina J Chavda, haematology SpR,
  2. Lucy Pickard, haematology SpR,
  3. Alison Thomas, consultant haematologist,
  4. James Uprichard
  1. St George’s University Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to S Chavda selinachavda{at}doctors.org.uk

A 22 year old woman was admitted to hospital with confusion, pyrexia, and two episodes of loss of consciousness while at work that day. She described having felt tired in the preceding week. She had no medical history of note and did not smoke or drink alcohol. She did not take any regular medications and did not use recreational drugs. The patient was born in the UK. Her parents were from Nigeria. She had no recent foreign travel or contact with anyone who was unwell.

Her heart rate was 115 beats/min, blood pressure 100/80 mm Hg, temperature 38.5°C, respiratory rate 20 breaths/min, and oxygen saturations 100% on room air. Blood results are shown in table 1 and blood film in fig 1.

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Table 1

Blood test results

Fig. 1

Blood film ×40 magnification

Questions

  1. What is the most likely diagnosis?

  2. What other initial tests are important?

  3. How is this condition treated?

Answers

1. What is the most likely diagnosis?

The following factors make thrombotic thrombocytopenic purpura (TTP) the most likely diagnosis:

  • microangiopathic haemolytic anaemia (indicated by the presence of schistocytes and  thrombocytopenia on the blood film) (fig 2)

  • ADAMTS13 enzyme activity <5%

  • normal coagulation screen (PT, APTT, fibrinogen)

  • normal haemolysis screen (liver biochemistry, haptoglobin, direct antiglobulin).

Fig. 2

Blood film ×40 magnification showing schistocytes and thrombocytopenia

TTP requires immediate haematologist assessment. TTP is a thrombotic microangiopathy. Haemolytic uraemic syndrome, another thrombotic microangiopathy, is a differential.

Thrombotic microangiopathy (TMA) is indicated by thrombocytopenia in the full blood count and microangiopathic haemolytic anaemia on the blood film.1 ADAMTS13 enzyme activity …

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