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Abstract Details

A 47 F with multiple sclerosis presented with left MCA acute ischemic stroke and NSTEMI due to atypical thrombotic thrombocytopenic purpura.
Cerebrovascular Disease and Interventional Neurology
P11 - Poster Session 11 (8:00 AM-9:00 AM)
4-008
47 F with multiple sclerosis, hypertension, CKD presented with right hemiparesis, right facial droop and aphasia. She was last seen normal at 5:45 am. On examination, afebrile, tachycardia, RR: 18, BP: 133/88, SpO2: 100%, GCS: 11, NIHSS: 24, insignificant general exam. All laboratory studies were at baseline compared to 3 weeks ago. Except, the platelet counts dropped from 262 to 115 and the troponin of 1.51. Non-contrast CTH showed no hemorrhage and CTA head and neck showed acute left MCA M2 occlusion. Patient received 90 mg of tPA at 10:15am and thrombectomy attempted but was unsuccessful. Patient was admitted to NSICU, tecfidera held, ASA and SQ heparin started 24 hours after thrombectomy, ciprofloxacin started for possible UTI. Initial Echo showed normal EF without wall motion abnormality. On day 3, her platelet counts continue to drop to 66 and hemoglobin dropped from 10.2 to 9.2. No evidence of bleeding. Stat hemolysis labs showed minimal evidence of hemolysis with LDH of 681, haptoglobin of 232, few schistocytes and fibrinogen of 604. Platelet counts continued to drop to 9 on day 6. On same day ADAMTS 13 level came back 12% with inhibitors which confirms TTP. Repeat labs showed LDH of 1400+, haptoglobin of 87. Urgent PLEX initiated with FFP. Immediately after first PLEX patient developed transfusion related lung injury vs pulmonary edema and was intubated. Repeat Echo showed moderate MR and mitral valve vegetation. Pt was started on IV ABx but all blood c/s remained negative. Patient also developed AKI. Aggressive diuretics and PLEX improved oxygenation. After initial treatment, TTP flared twice requiring PLEX and prednisone. 
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This was an atypical presentation of TTP with minimal evidence of hemolysis but severe thrombotic events of acute ischemic stroke, NSTEMI and culture negative endocarditis in a patient with multiple sclerosis.
Authors/Disclosures
Ronak Patel, MBBS (Sentara Norfolk General Hospital)
PRESENTER 		No disclosure on file
Hartmut Uschmann, MD (University of Mississippi Medical Center) Dr. Uschmann has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Samson & Powers, PLLC.