1. Megan Buchholz presentation: case study

2. TTP Case Study 41 year old woman
PMHx : Chronic Anemia, Rheumatoid Arthritis, UGIB (Upper Gastric Intestinal bleed)
March 20th, 2012 presented to her GP with abdominal pain.
CBC showed plt count of 17, Hg 101
Urine dip positive for blood and protein
Started on Cipro for dx of UTI
Sent home

3. 2 days later she returns to her GP The next day she goes to the ER
Worsening pain and general malaise
Abx changed, Tylenol #3 added
The next day she goes to the ER
Presented with c/o of feeling very unwell
Plts 12
S/B Haeme – dx ITP
Started on Prednisone 1mg/kg/day with f/u in 1 week

4. The next day her son brings her back to the ER
She is very confused
In ER has seizure, followed by decreased LOC
She is intubated, medicated and transferred to their ICU. Hg 72 and plts 12, moderate fragments on film.
Transferred to SMH ICU with Dx of TTP (March 25, 2012)

5. Course of treatment as St. Michael’s
Plts 6, LDH 1189, Hg 100, Cr 118, on admission
Started on Plasmapheresis 1.0 PV that day, Prednisone 1mg/kg started
Exchanged with CSP.
Treatment #8 c/o ‘itchiness’. Tx’d with 50 mg Benadryl IV. Experienced Hematological deterioration. ↓plts, ↑LDH, Code blue, seized – transferred to ICU
Changed daily PLEX to 1.5 PV, Given Rituximab x 4
Had 19 treatments in total
Plts 213, LDH 135, Hg 123, Cr 46, on discharge

6. Refractory Relapse 2 months later
(June 21, 2012)
Again started with 1.0 PV exchange with CSP
During Treatment #9 (as an out pt)
Pt c/o feeling ‘itchy’. Whole body hives noted. 50 mg Benadryl IV
Pt then c/o ‘feeling on fire’. Hydrocortisone 100 mg IV given. PLEX stopped, rinse-back started.
Then c/o difficulty breathing. O2 4L NP applied. O2 sat 85%, BP 67/36
NS 700 cc given via bolus
Face started to swell, 0.25 mg Epinephrine IM given
BP ↑ 110/72, transferred to Emergency Department
Monitored x 24 and sent home. Discontinued PLEX
Plts 258, LDH 142, Hg 108, Cr 52
Total number of treatments 9

7. Refractory Relapse 2 weeks later
(July 13th, 2012)
Presented in follow up clinic Plts 14, LDH 360, Hg 128, Cr 48
Re-initiated Plasmapheresis at 1.0 PV
Exchanged with SDP
Better after 8 treatments.
Zero allergic reactions
Plts 173, LDH 185, Hg 108, Cr 55 on discharge
No relapses since