Simultaneous ischemic and hemorrhagic lesions of the brain detected by CT scan in a patient with thrombotic thrombocytopenic purpura.

Correspondence: Fabio Guzzini, M.D., Department of Emergency Medicine, Ospedale, piazzale Borella 1, 21047 Saronno, Italy. Tel. international +39-2-9613251 • Fax international +39-2-9613214. Although overt clinical abnormalities are present, brain CT scans may be normal in patients with thrombotic thrombocytopenic purpura (TTP). Nonetheless a study form a large series at the Mayo Clinic showed that CT can predict outcome, since abnormal findings are related with more severe and nonreversible neurological defects and with a significant higher mortality.1 A 45-year-old man was admitted because of intense pain in the neck and left shoulder. His remote clinical history included a right hemicolectomy, performed 4 months earlier for adenocarcinoma, and followed by cyclic chemotherapy with 5fluorouracil and folinic acid. At the time of surgery no metastatic involvement was found. Four days after admission the patient manifested confusion, behavioral changes and agitation, which rapidly worsened to stupor and coma. A mild left hemiparesis was also noticed. At the same time he became icteric and showed multiple hemorrhages (petechiae and cutaneous hematomas, oral bleeding, hematuria). Blood parameters revealed increasing anemia (Hb from 13.6 to 8.1 g/dL), and thrombocytopenia (till 193109/L), bilirubin 4 mg/dl (indirect 3.6), lactic dehydrogenase 3.875 U/L, negative Coombs’ tests and renal function impairment, while PT, PTT, fibrinogen and antithrombin III levels remained normal and only a slight increase of fibrinogen degradation products was observed (80 mg/L). CT scans were performed on day 5, 6 and 9 from admission. All three detected multiple simultaneous ischemic and hemorrhagic lesions (intraparenchymal and ventricular) in both cerebral hemispheres (Figures 1,2,3) before any treatment. Starting the 5th day, the patient was treated with plasma-exchange, dexamethasone 8 mg b.i.d. and 250-mg of lysine-acetylsalicylate, but his clinical condition progressively worsened until death on the 11th day. Neither chest and abdominal CT nor skeletal radionuclide scans showed a metastatic lesion, neverthless the titer of plasma carcinoembrionic antigen (CEA) was elevated (over 70 ng/mL). Autopsy was not performed. The patient herein described showed the typical features allowing the diagnosis of TTP.2,3 CT scans detected the presence of both ischemic and hemorrhagic lesions, before any anticoagulant or antiplatelet treatment was started. This finding is extremely rare: to the best of our knowledge it has never been reported in the literature. Ocular involvement has been previously described in this journal.4