Question 26.3

A previously healthy 34-year-old female is transferred to your hospital intubated and ventilated with a history of a prolonged generalized tonic-clonic convulsion. On arrival, she is deeply unconscious with a GCS of 3, fixed dilated pupils, absent tendon reflexes and bilateral up-going plantar reflexes. An admission CT scan shows bilateral intracerebral haemorrhages.

A full blood count report is as follows:

Test	Value	Normal Adult Range
Haemoglobin*	78 G/L	115 – 155
White Cell Count*	14.5 x 109 / L	4.0 – 11.0
Platelets*	43 x 109 /L	150 – 300

Blood picture:

Thrombocytopaenia, fragmented red cells and reticulocytosis.

Based on the history, CT findings and full blood count report, give three possible diagnoses.

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College Answer

Eclampsia
TTP
HUS
Meningococcal meningitis with DIC (big bleed less likely)
Vasculitis

Discussion

The combination of thrombocytopenia, haemorrhage and a MAHA-like blood film all suggest the following differentials:

Eclampsia and HELP syndrome
MAHA with vasculitis - the fragmented red cells and thrombocytopenia generally suggest some sort of consumptive coagulopathy
TTP - this can present with neurological symptoms, which are due to microvascular occlusion - it is concievable that these patients might have seziures and intracranial haemorrhage
HUS - however no renal function findings are available
DIC due to sepsis (which, I suppose, could be meningits-associated - and meningococcal meningitis is the more likely one to cause DIC)
Infective endocarditis - septic emboli with haemorrhagic transformation

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