A 40-year-old female, with a past medical history significant for obesity and smoking, was seen by her PCP for symptoms of fatigue and a skin rash. Laboratory tests indicated that her blood count and platelets were normal but that her blood sugar was elevated at 843 (nl=65-110). The physician diagnosed Type II Diabetes Mellitus (DM) and placed the patient on an oral antiglycemic medication.
Over the next five months, the patient was seen by the same physician multiple times for various complaints (continued fatigue, thirst, rectal bleeding and abdominal pain). An abdominal ultrasound revealed an enlarged liver consistent with fatty infiltrates; her liver enzymes were also slightly elevated. During a GI consult, a rectal exam was deferred, secondary to menses; stool cards were given but never returned. Her sedimentation rate was found to be elevated. EKG was slightly abnormal (non-specific T wave changes), but a followed-up echocardiogram/stress test was normal.
Four months after the stress test, she saw her PCP for the sudden onset of a rash. She was given Medrol and Atarax, and returned within three weeks for lab testing. The results were available within two days but not reviewed by her PCP for an additional week. Results included a platelet count of 59 (nl = 150-450) - a drop from 302 (the previous year); continued abnormal LFTs, and an elevated HgA1C (10.8). The physician noted "labs awful" in her chart.
At an appointment four days later, the patient admitted to not following her diet or checking her blood sugars. With continued complaints of skin problems, she was diagnosed with recurrent sebaceous cysts, and given antibiotics. Her PCP also prescribed Glucophage and encouraged her to check her blood sugars and see the dietician. She was also instructed to discontinue any aspirin and Motrin, secondary to her decreased platelet count, and to return in two weeks.
Within two days, she again developed abdominal pain, followed by feelings of confusion and slurred speech, and was taken to her local ED. Her lab results revealed a low hematocrit (16.3), platelets = 8; with ABGs, LFTs, electrolytes and sugars abnormal. A head CT showed no sign of an acute bleed. Within three hours of arrival at the ED, she suffered a grand mal seizure, was intubated, and given two units of blood. Her heart rate and temperature were elevated, and she was transferred to a tertiary hospital. Lab work revealed increased multiple schistocytes, diagnostic of thrombotic thrombocytopenic purpura (TTP - a rare, life-threatening disease characterized by a widespread aggregation of platelets throughout the body, neurological dysfunction and renal insufficiency, resulting in blood clots in small blood vessels throughout the body1). Less than one hour after her transfer she experienced a cardiac arrest and died.