[Ticlopidine-associated thrombotic thrombocytopenic purpura (Morbus Moschcowitz)]

A 75-year-old woman with a history of recurrent ischemic cerebral events was admitted with acute unspecific neurological symptoms and fever.

Intracerebral hemorrhage due to hypertension and antithrombotic therapy with ticlopidine was ruled out with cranial computed tomography. Laboratory findings on admission included thrombocytopenia (12/nl), renal insufficiency (serum creatinine 1.6 mg/dl) and LDH elevation (1,218 U/l). The hemoglobin on admission was normal.

In the presence of rapidly declining hemoglobin values and fragmentation of red cells thrombotic-thrombocytopenic purpura (TTP) was diagnosed and the patient received fresh frozen plasma. Shortly after the plasma infusion the patient's condition deteriorated rapidly showing clinical signs of an allergic shock. In the sequel of 24 to 48 hours the patient developed renal failure, severe anemia and the thrombocyte count fell to 5/nl. The patient was mechanically ventilated during the next 48 hours and needed intravenous catecholamines. Even after restoration of spontaneous respiration and cessation of pharmacological sedation the patient remained comatose. Cranial computed tomography on the fourth day after admission showed multiple infarction syndrome. The patient died on the ninth day after admission in status epilepticus which could not be stopped with pharmacological means.

The combination of neurological symptoms, thrombocytopenia, fever, renal failure and hemolytic anemia in a patient taking ticlopidine points to a diagnosis of TTP. The high mortality of TTP can probably only be reduced by early plasmapheresis.