30 yo F presents with nausea, vomiting, and diarrhea

OBJECTIVES:

  • Name the differential diagnosis of a hemolytic anemia and thrombocytopenia

CASE:

30 yo F presents with a history of epilepsy 2 weeks of subjective fevers/chills and 1 week of nausea/vomiting/diarrhea. Her GI symptoms started after she ate at a Chinese buffet with her family but no other family members developed similar symptoms. She reports nonbloody, nonbilious emesis and denies melanotic or bloody diarrhea. She has been unable to keep down any fluids or medications. ROS is notable for a frontal headache and an increased frequency of seizures. She also reports fatigue, malaise and menorrhagia, but no other spontaneous bleeding or bruising. 

She has a history of epilepsy and is on leveteracitam, topiramate and carbamazepine, without recent changes in medications. She has a 10 pack smoking history, but no other substance use.

On exam, she is afebrile, HR 90s, BPs 123/54 and appears comfortable on exam. She has scant dried blood and a blood blister on her lower lip, dry  mucus membranes. She has multiple ecchymoses around her IV site but no signs of active bleeding. Her initial labs are notable for a Cr of 1.64, WBC of 7.5, hct 13, platelets of 9 (all normal at baseline).

What additional work-up would you want? 

What is your differential diagnosis? 

What would you do next? 


CASE CONTINUED:

FINAL DIAGNOSIS:

When should you suspect this diagnosis? 

How do you diagnose it? 

What are the signs and symptoms of this disease? 

How do you treat it? 

Can you transfuse platelets in patients with this disease?


TAKE HOME POINTS: 


ADDITIONAL LEARNING:


REFERENCES:

  1. George, JN & Nester, C.  Approach to the patient with suspected TTP, HUS, or other TMA. In: UpToDate, Timauer, JS (Ed), UpToDate, Waltham, MA. (Accessed on March 04, 2017.)
  2. George, JN & Nester, CM. 2014. Syndromes of Thrombotic Microangiopathy. NEJM. 371:654-666.
  3. George, JN & Cuker, A. Acquired TTP: Clinical manifestations and diagnosis. In: UpToDate, Timauer, JS (Ed), UpToDate, Waltham, MA. (Accessed on March 04, 2017.)
  4. Niaduet, J. Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) in children. In: UpToDate, Kim, MS (Ed), UpToDate, Waltham, MA. (Accessed on March 04, 2017.)
  5. Swisher, KK, et al. 2009. Clinical outcomes after platelet transfusions in patients with thrombotic thrombocytopenic purpura. Transfusion. 49:873-887
  6. Goel, R, et al. 2015. Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality. BLOOD. 125(9):1470-1476