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A man with transient ischaemic attack and thrombocytopenia

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6472 (Published 30 October 2014) Cite this as: BMJ 2014;349:g6472
  1. Muhajir Mohamed, consultant haematologist; associate professor of medicine12,
  2. Jocelyn Tan, trainee registrar3
  1. 1Launceston General Hospital, Launceston, TAS 7250, Australia
  2. 2Launceston Clinical School, University of Tasmania, TAS, Australia
  3. 3Department of Medicine, Launceston General Hospital, Launceston, TAS, Australia
  1. Correspondence to: M Mohamed muhajirbm{at}yahoo.com

A 51 year old man presented to the emergency department with sudden onset of right upper limb weakness and slurring of speech, associated with intermittent headaches. He had no medical history of note. He had smoked 10-15 cigarettes a day for 30 years and had no history of excessive alcohol intake. Neurological examination showed weakness of the upper motor neurones of the right upper limb and right side of the face, but no other neurological signs. Cardiac, respiratory, and abdominal examinations were normal. The neurological signs spontaneously recovered within four hours, and computed tomography of the brain showed no abnormalities.

Full blood counts showed low haemoglobin (92 g/L; normal range 130-180), a low platelet count (28×109/L; 140-440), and a high neutrophil count (11×109/L; 2-8). A blood smear showed red blood cells with morphological abnormalities (fig 1). His absolute reticulocyte count (235×109/L; 50-100) and serum lactate dehydrogenase (814 U/L; 125-243) were raised, and serum haptoglobin was undetectable; however, his bilirubin concentration was normal. A direct antiglobin test was negative. His prothrombin time, activated partial thromboplastin time, and fibrinogen concentration were within normal limits. Serum creatinine, liver function tests, lipid profile, and iron studies were also within the normal ranges.

Questions

  • 1. Describe the findings on the blood film?

  • 2. What is the most likely diagnosis in this patient?

  • 3. What are the differential diagnoses?

  • 4. What additional investigations are needed?

  • 5. How should the patient be managed and what is the prognosis?

1. Describe the findings on the blood film?

Short answer

His blood film shows an abundance of schistocytes, a few spherocytes, polychromasia, and thrombocytopenia. These features are suggestive of microangiopathic haemolytic anaemia.

Long answer

Schistocytes are fragmented red blood cells that are detected by microscopy in peripheral blood films stained by standard procedures. These abnormalities are caused by extrinsic mechanical damage to red cells within …

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