Discussion: This case emphasizes a complex case of DKA with persistent tachycardia and an initially unclear etiology. Infectious and ischemic workups were negative, and the patient reported adherence to her insulin regimen, thus, ruling out common causes of DKA. This is a rare case of new-onset Grave’s Disease presenting as thyroid toxicosis inciting DKA.
every five hours, PTU 200 mg every four hours, and potassium iodine 50 mg every six hours, as well as management of DKA with clinical improvement. Thyroid ultrasound showed toxic multinodular goiter. She was discharged on Methimazole 5mg three times a day with close endocrine follow-up.
PSEUDO-THROMBOTIC MICROANGIOPATHY SECONDARY TO B12 DEFICIENCY Karam Rahat MD 1 , Ricardo Vallejo-Calzada MD 1 , Graham Unis MD 1 , Drishti Chawla, MS 2 ; Department of Medicine, Ochsner Medical Center, New Orleans, LA 1 ; University of Queensland-Ochsner School of Medicine, New Orleans, LA 2 .
Introduction: Vitamin B12 deficiency has a variable presentation with hematologic and neurologic sequelae, pseudo-TMA a rarity among them. While Pseudo-TMA shares many features with thrombotic thrombocytopenic purpura (TTP), including hemolytic anemia, thrombocytopenia, and schistocytosis, management of TTP involves plasma exchange and other therapies that are neither therapeutic nor benign in regard to B12 deficiency. Early recognition of pseudo-TMA can prevent misdiagnosis and potentially ineffective therapies. Case: A 58-year-old female with no known history brought by her family after being found down on the bathroom floor with severe lethargy and confusion, last contact 2 days before arrival. Workup was notable for Hgb 2.6 g/dL, MCV 95FL, PLT 71,000/MCL. LDH 3500 Unit/L, Haptoglobin 19 mg/dL, negative direct coomb’s test, bilirubin 2.2, reticulocyte 0.7%, reticulocyte index 0.06, ptt 21.4, INR 1.3, Fibrinogen 315. Peripheral blood smear notable for schistocytes, teardrop cells, and hypersegmented neutrophils. The patient was transferred to a higher level of care due to concern for TTP given AMS and concurrent AKI. However, serum B12 and folate
were <148 and 2.2 respectively, homocysteine >50, and PLASMIC score of 2. ADAMTS13 activity was normal. Intravenous B12 and Folate repletion were initiated with sustained improvement in mental status and bi-cytopenia over the hospital course. An intrinsic blocking factor was sent and later returned positive. The patient’s additional acute medical problems were managed and later discharged with monthly B12 injections and Hematology follow-up. Discussion: Recognition of factors with a negative predictive value for TTP may distinguish Pseudo- TMA from TTP. Studies have shown a few labs that can help distinguish these syndromes, including reticulocyte index, which is high in TTP and low in pseudo-TMA, as well as LDH, which can be markedly elevated in pseudo-TMA, as seen in our patient. Careful evaluation of the peripheral blood smear is also vital, as the presence of tear drop cells and megaloblastic changes points more towards pseudo-TMA. While it is critical to rule out more life-threatening primary TMA syndromes, pseudo- TMA should not be overlooked, especially in those who present with severe vitamin B12 deficiency.
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