A 54-year-old man, with a personal history of DM, hypertension and mild chronic renal insufficiency, presented with somnolence and right hemiparesis. Laboratory tests: creatinine 2.3 mg/dl, Hb 10.3 g/dl and platelets 20000 mm3, with normal coagulation. Cranial CT: ischemic lesions with microhemorrhagic necrosis. Subsequently, he began with progressive deterioration of the level of consciousness and increase of Cr, LDH and unconjugated bilirubin. Direct Coombs' test was negative. Schistocytes in smear. In view of the diagnostic suspicion, the following conduct is to be followed:
Let's see: a patient with certain history who has: - Schistocytes in smear: indicates microangiopathic anemia, red cell rupture of mechanical cause, which can be seen mainly in PTT, autoimmune hemolytic anemia and DIC. - Bicytopenia: here the causes can be very, very varied. - Elevation of LDH and Bilirubin, which indicates a massive rupture of red blood cells. - Negative direct Coombs' test: essential data, indicating that there is no antibody that sticks to the red blood cells. With these wickers we are going to weave the basket: Answer 1: it cannot be because a hemorrhagic transformation does not give such a brutal elevation of LDH and Cr, in addition to not explaining schistocytosis. Answer 2: urgent plasmapheresis... in case of thrombotic thrombocytopenic purpura, yes; I like this answer because it justifies bicytopenia, since microangiopathic hemolytic anemia is produced by rupture of red blood cells when they are fragmented by ultralong von Willebrand factor multimers in case of deficiency of the ADAMST13 enzyme, resulting in brutal platelet aggregates and the flow cytometer does not count 400 platelets, but a molondron of platelets that form a mass, hence the thrombocytopenia. It also explains the negative direct Coombs, elevated LDH and Cr. Answer 3: a situation as critical as that patient's indicates that something big is going on and I would not sit and wait for glucocorticoids to take effect...and I do not know right now what pathology gives that symptomatology and has that treatment as standard. Answer 4: looking for a trigger for DIC...it would make sense if it were not for the fact that in DIC it is VERY characteristic the consumption of coagulation factors, which is not present in this case. Answer 5: a myeloma does not give schistocytosis nor does it have this symptomatology, they would have to give other data that would support this pathology, such as bone pain and hypercalcemia...
New cranial CT in the presence of suspected hemorrhagic transformation of ischemic stroke.
Initiate urgent plasmapheresis.
Beginning of treatment with glucocorticoids at a dose of 1 mg/kg/day.
Search for triggering cause of DIC.
Suspected multiple myeloma: bone marrow aspirate.
Answer 1: it cannot be because a hemorrhagic transformation does not give such a brutal elevation of LDH and Cr, in addition to not explaining schistocytosis.
Answer 2: urgent plasmapheresis... in case of thrombotic thrombocytopenic purpura, yes;
Answer 3: a situation as critical as that patient's indicates that something big is going on and I would not sit and wait for glucocorticoids to take effect...and
Answer 4: looking for a trigger for DIC...it would make sense if it were not for the fact that in DIC it is VERY characteristic the consumption of coagulation factors, which is not present in this case.
Answer 5: a myeloma does not give schistocytosis nor does it have this symptomatology, they would have to give other data that would support this pathology, such as bone pain and hypercalcemia...