Thrombocytopenia and red cell fragmentation in the critically ill: a case report

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<span style="font-size: 10pt;"><span style="color: #4a4a4a; font-family: Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; text-decoration-color: initial;">A 66-year-old male patient with a history of hypertrophic obstructive cardiomyopathy presented to the emergency department having been generally unwell for 24 hours. He collapsed whilst gardening and was later found unconscious on the kitchen floor for two minutes by his family. On arrival he was febrile (37.8degreeC), tachycardic (112 bpm), in respiratory distress (40 breaths per minute, 82% oxyhaemoglobin saturation on room air) with reduced conscious state (GCS 9). Arterial blood gas demonstrated type 1 respiratory failure (pH 7.45, pO2 6.34 kPa, pCO2 4.68 kPa, lactate 0.9 mmol/l, base excess 1.1 mmol/l) with falling GCS he was intubated and ventilated. His systolic blood pressure declined to 66 mmHg and noradrenaline was commenced on the Intensive Care Unit. CT head demonstrated no haemorrhage or acute infarct. ECG displayed old LBBB. Admission bloods showed Hb 72 g/l, WCC 11.68 x 10/l, Plt 173 x 10/l, MCV 105 fl, Cr 81 mumol/l, bilirubin 31 mumol/l, normal clotting, CRP 30 mg/l, troponin 48 (0-14). Empirical intravenous co-amoxiclav and clarithromycin were administered for suspected community-acquired pneumonia. Prophylactic low molecular weight heparin was administered daily. He was transfused 2 packed red blood cell units with no significant response in haemoglobin. The following day he clinically improved and was extubated. A day later he was saturating at 97% on 2 litres of oxygen via nasal cannulae, off vasopressor support and fully orientated (GCS 15). However blood tests revealed progressive thrombocytopenia with Hb 69 g/l, Plt 50 x 10/l, PT 10.8 s, APTT 34 s, fibrinogen 4.83 g/l, LDH 767 IU/l, reticulocyte count 12.8 (0.57%). A blood film con-firmed thrombocytopenia, neutrophil hypersegmentation and red cell fragments. ADAMTS-13 activity was 48%. Haematinics revealed severe vitamin B12 deficiency (<100 pg/ml). Hydroxycobalamin was ini-tiated and his counts normalised with reticulocytosis. Thrombocytopenia and anaemia are common in critically ill patients. This case highlights macrocytosis and reticulocytopenia as important feature distinguishing severe B12 deficiency from other causes of red cell fragmentation.</span> [Conference abstract]</span>