Fluctuating neurological symptoms: should I call the neurologist or the hematologist?

Objectives: The objective of this study was to highlight the role of the clinical laboratory and the relevance of reporting the case immediately to the unit of hematology for the diagnosis and early administration of treatment in the presence of such an urgent hematologic disease as thrombotic thrombocytopenic purpura (TTP).

Case Presentation: An elderly patient was referred to the emergency department of our hospital by his general practitioner for speech difficulty, facial asymmetry and weakness in the upper limb. Stroke code was activated. However, laboratory findings (anemia, thrombocytopenia, elevated creatinine, total bilirubin and LDH, negative direct Coombs test) and presence of schistocytes in the peripheral blood smear test were consistent with a completely different diagnosis: TTP thrombotic microangiopathy.

Conclusions: The first diagnostic approach of left hemispheric stroke was not confirmed in the laboratory, with findings of nonautoimmune hemolytic anemia, thrombocytopenia without apparent cause and presence of schistocytes. We should not forget that the clinical manifestations of this condition are widely variable and may include multiorganic dysfunction. Although confirmation of diagnosis is based on ADAMTS-13, its associated high mortalitiy requires immediate treatment on mere suspicion.