30 Jun 2022

12/3/20: Thrombotic Thrombocytopenic Purpura (TTP)

PGY2 David Panek presented a case of a 56 year old female with history of HIV (last CD4 count 194 on 7/2020) and recently diagnosed metastatic triple negative breast cancer currently receiving palliative chemotherapy who presents with dizziness and weakness over the past week.  She presented to Ed from oncology clinic after a code assist was called when patient reported severe dizziness during her infusion visit.  Dizziness described as lightheadedness rather than vertiginous.  She also reports worsening nausea, reduced PO intake, mild headache and weakness in her legs that has made ambulation more difficult.  Also reports mild shortness of breath and dry cough.  She denies fevers, though does note some dysuria ongoing for the past 2 weeks.  Of note, patient was planning on starting cycle 5 of chemotherapy/immunotherapy (comprised of Paclitaxel and Atezolizumab).  She denies feeling similar symptoms with previous cycles.  Home medications include Biktarvy and Nitrofurantoin 100mg BID.  She used to work in security but now unemployed, and has daily ETOH use, ¼ ppd for 5 years and daily marijuana use.

Vitals: T 36.6, HR 100, RR 16, BP 149/76, O2 sat 100% on RA

Physical Exam significant for female appearing comfortable, A&Ox4, no acute distress, pallor conjunctiva, normal cardiac and pulm exam, soft abdomen, no bruises/rashes on skin and LUE notably swollen compared to RUE.

CBC: WBC 4.1> Hb 7.4/Hct 21.8 <Plt 20 (MCV 88.2, RDW 18.7%)


Na 139/K 3.7/Cl 98/HCO3 24/BUN 11/Cr 0.45 <Glucose 125

ALP 131>T.protein 6.6/Albumin 3.9/AST 179/ALT 88/Tbili 2.6/Dbili 0.8

Ca 9.8, Mg 1.8, Phos 2.0

Coags: PT 14.7, INR 1.15, PTT 33.9

 Infectious workup initiated with the following findings:

  • BCx, UCx negative
  • COVID-19 not detected
  • Lactate 5.7 mmol/L (normal 0.5-2.2)
  • Acute hepatitis panel negative
  • CD4: 194/cumm
  • HIV-1 RNA copies <20 copies/mL

Hematology workup initiated, with the following significant findings:

  • Retic %: 6%
  • Abs Retic: 145 x10^9/L
  • LDH: 1737 (normal 135 – 225)
  • Haptoglobin: <10 (normal: 30 – 200)
  • Fibrinogen: 222 (normal 237 – 481)
  • UA: 100 protein, large blood (6-10 RBC), small leuks (11-30), positive nitrite
  • DAT negative
  • ADAMTS13 activity: <3% activity
  • Peripheral smear done with multiple schistocytes and spherocytes

Treatment: Stat CTH done with no evidence of bleed and patient with no focal neurological deficits.  Given peripheral smear and labs, Heme was consulted for concern of TTP likely 2/2 immunotherapy (Atezolizumab).  She was given 2U FFP and started on Solumedrol 1g IV qday x3 days and initiation of plasmapheresis.

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