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

  1. Eclampsia
  2. TTP
  3. HUS
  4. Meningococcal meningitis with DIC (big bleed less likely)
  5. 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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