A 22 yr Female, P2, last baby 1year old has complaint of sudden onset purpuric spot in both the lower limbs which bled occasionally. She was seen by her local physician who has diagnosed her a case dengue (Platelets 60 K & IgG positive). Next day her platelets dropped to 30 k and Hb dropped to 6 gm. She was given 2 SDP and 2 PCV. Next day reports Hb 5 gm%. Platelets 10,000 , LFT normal . She was send to district place where she was treated as dengue only and they gave 3 more PCV, 2 SDP, & 10 PLATELETS but her Hb & Platelets was dropping, on 5th day Doctor noticed abdominal distension, USG abdomen done which shoed intrabdominal bleeding with pelvic collection of collected hematoma. She shifted to us with Tachycardia (HR 160), BP 120/70), RR 35, SPO2 80% RA, and passing good amount of urine. She was carrying blood reports (Hb 2 gm%, Plt 5000, TLS 13000, PT& aPTT Normal, Na 122, K 2.3) Apart from this no other report was done.
This patient came to me at 10:30 pm, and we got these reports done (CBC- Hb 2 gm%, TLC 17000,Platelets- 3000, PT- INR 1.20, aPTT-35/30, LFT-Bilirubin 1.8, RFT-Normal, ANA profile Positive for scl1, ferritin-Normal, Triglyceride Normal, USG abdomen- collection in pelvis adnexal mass hepato-spleenomegaly, Beta-HCG normal, Smear for fragmented RBCs- Absent , MP -QBC/antigen- Negative Dengue IgG titer- normal , Scrub typhus antigen -negative , Direct coombs test positive, ABG pH-7.50, PCO2-26, PaO2-110/10 liter O2, HCO3-22,. These reports came to me 1230 midnight , by that time I had arranged 4 PCV & 1 SDP.
My clinical diagnosis was ITP , on further history relative told me that patient used to have these kinds of purpuric bleed in past but it used to resolve . Before blood transfusion we gave 1 gm methyl prednisolone and 50 gm IVIG ( 10 vials of 5 gm) and then transfused the 4 PCV & 1 SDP. By morning patient got stabilized. We got BMA / Biopsy done next day which confirmed the diagnosis of ITP. Next day we again repeated the 1 gm methyl prednisolone and 50 gm IVIG ( 10 vials of 5 gm) and 1 SDP. She did not need any more PCV transfusion and Platelets transfusion . We gave her methyl prednisolone (1gm) for 5 days . Her platelets started improving on 3rd day and 5th day it came to 1 lakh. We got USG abdomen & CT abdomen which showed resolving hematoma.
We sent her home on 6th day on steroid, HCQs.
Fulminant ITP ANA (ScL) associated.
