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A 39-year-old male patien t is admitted to the ICU with chest pain, slurred speech, and left-sided weakness . Past medical h istory is sign i fican t For hypothyroidism, angina, and bipolar d isorder. Home medications incl ude val proic acid, levothyroxine, and sublingual n itroglyceri n. On physical exam , he is in mild distress, afebri le, and mi ldly hypertensive. Complete blood count shows a leukocyte count of 6,600/,uL, hemoglobin 6.5 g/dl, and platelet count 1 6, 000/,uL. Creatinine is 0.8 mg/dl and LDH is 683 U/L. Troponin level is normal. The peri pheral blood smear is shown below.
What is the most important step in the management of this patient?
- Begin high-dose steroids
- Platelet transfusions to keep platelets > 30,000/ ,LLL
- Plasma exchange
- Neurology consultation
Medicine
C. The peripheral blood smear shows schistocytes, helmet cells, polychromasia, and thrombo-cytopenia. Microangiopathic hemolytic anemia and thrombocytopenia should raise a suspicion forthrombotic thrombocytopenic purpura (TTP), and plasma exchange should be started immediately, due to the high mortality rate of untreated thrombotic thrombocytopenic purpura. Steroids have been in-cluded in the treatment ofTTP, but are not as important as initiating plasma exchange. Platelet transfu-sions should be avoided unless there is significant bleeding, since it has been reported to be associated with an increased risk of thrombotic events. Neurology consultation would delay therapy unnecessarily.
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