Parekh Hiral D, Reese Jessica A, Cobb Patrick W, George James N
Department of Medicine, College of Medicine, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma.
Am J Hematol. 2015 Mar;90(3):264-6. doi: 10.1002/ajh.23840. Epub 2014 Sep 26.
A 48 year-old white man was hospitalized for evaluation of back pain. At time he reported that he had been in excellent health until three months before his hospitalization when he noticed difficulty walking when he got out of his car following a long trip. He said that “it just felt as though my legs wouldn’t move very well”. He did not see a doctor since this problem resolved within several days. Three weeks before his hospitalization, he thought he “had a viral illness” with cough and fatigue that persisted, together with subsequent abdominal discomfort. His primary care physician noted that his platelet and white blood cell counts were low which he attributed to a viral infection. An abdominal ultrasound reported minimal splenomegaly. He was treated with antibiotics and prednisone; all of his symptoms resolved and his platelet count increased. One week before his hospitalization he developed low back pain which made walking difficult. He also had fever and sweats. When these symptoms persisted he was admitted to the hospital. His physical examination was normal. His spleen was not palpable; he had no lymphadenopathy; his neurologic examination, including his gait, was normal. He had no back tenderness. His platelet count was 23,000/µL; white blood cell count, 3700/µL with a normal differential; hemoglobin, 13.5 gm/dL; creatinine, 1.7 mg/dL; LDH, 1737 U/L (normal, <190 U/L). Coagulation tests were normal; fibrinogen was 858 mg/dL. Examination of the peripheral blood smear demonstrated schistocytes and normal white cell morphology. Thrombotic thrombocytopenic purpura (TTP) was suspected because of the thrombocytopenia, red cell fragmentation, high serum LDH and creatinine, the history of fever, the possibility that the difficulty walking may have been a neurologic manifestation of TTP, and – most important – no apparent alternative etiology. Treatment with plasma exchange (PEX) and corticosteroids was begun.
一名48岁的白人男性因背痛入院接受评估。当时他报告称,在住院前三个月之前他一直身体健康,直到一次长途旅行后下车时他发现行走困难。他说:“感觉就好像我的腿不太能正常活动了”。由于这个问题在几天内就自行缓解了,所以他没有去看医生。住院前三周,他认为自己“患了病毒性疾病”,伴有持续的咳嗽和疲劳,随后又出现了腹部不适。他的初级保健医生注意到他的血小板和白细胞计数偏低,认为这是由病毒感染引起的。腹部超声检查显示脾脏轻度肿大。他接受了抗生素和泼尼松治疗;所有症状都得到缓解,血小板计数也有所上升。住院前一周,他出现了下背部疼痛,导致行走困难。他还伴有发热和盗汗。当这些症状持续存在时,他被收治入院。他的体格检查结果正常。脾脏未触及;无淋巴结肿大;包括步态在内的神经系统检查均正常。他没有背部压痛。他的血小板计数为23,000/µL;白细胞计数为3700/µL,分类正常;血红蛋白为13.5 gm/dL;肌酐为1.7 mg/dL;乳酸脱氢酶(LDH)为1737 U/L(正常范围,<190 U/L)。凝血检查正常;纤维蛋白原为858 mg/dL。外周血涂片检查发现裂红细胞,白细胞形态正常。由于存在血小板减少、红细胞碎片、血清LDH和肌酐升高、发热病史、行走困难可能是血栓性血小板减少性紫癜(TTP)的神经系统表现,以及最重要的是没有明显的其他病因,故怀疑为TTP。于是开始采用血浆置换(PEX)和皮质类固醇进行治疗。