Introduction: Thombotic thrombocytopenic purpura (TTP) is a rare hematological emergency condition that is almost always fatal if early diagnosis is not made and appropriate treatment is not initiated promptly. As TTP can present with variety of neurological symptoms and signs, it is important for general physicians, stroke physicians and neurologists to have high suspicion of TTP when there is unexplained mild anemia and or thrombocytopenia in stroke patients.
Case Presentation: We present a case of a 36-year-old woman who was diagnosed with TTP and treated with urgent plasma exchange within 24 hours of hospital presentation with left homonymous hemianopia. She presented to emergency department with sudden onset of reduced left sided peripheral vision, and severe thrombocytopenia, mild anemia, mild acute kidney injury were incidentally found without other focal neurological deficits and fever. TTP was suspected immediately and hemolytic anemia was confirmed on blood film and other markers for hemolysis (low haptoglobin, raised reticulocytes). She was transferred to ICU for urgent plasma exchange whilst waiting for ADAM TS 13 level result. MR brain revealed multi-territory embolic infarcts and ADAM TS 13 level came back as undetectable. She was treated with multiple sessions of plasma exchange, methyl prednisolone and rituximab successfully. Her homonymous hemianopia improved gradually and she has been closely followed up by hematology team in clinic for ongoing treatment of acquired TTP with positive autoantibody inhibitor to ADAM TS 13.
Conclusion: Acquired TTP is a rare condition and above case shows atypical presentation of TTP with initial symptom of left homonymous hemianopia and incidental finding of severe thrombocytopenia, mild anemia and mild acute kidney injury on routine full blood count and biochemistry. This case highlights the importance of early diagnosis of TTP in young stroke patient to have effective early management to avoid mortality and morbidity.