Laboratory tests revealed the following results: hemoglobin: 6.7
g/dL; MCV: 88 fL; platelets: 13,000/L; total bilirubin: 5.3 mg/dL with
indirect bilirubin: 3.2 mg/dL; LDH: 3981 U/L; retic percentage: 3%;
International Normalized Ratio (INR): 1.3; creatinine: 1.3 mg/dL;
cardiac troponin I level: 410 ng/mL; amylase: 390 U/L; and lipase: 510
U/L. Test results for direct and indirect Coombs tests were negative.
The patient’s peripheral blood smear showed the presence of
schistocytes(Figure 1). ADAMTS-13 activity level was 0% with elevated
inhibitor titer and negative anti-nuclear antibody level. The patient’s
electrocardiogram showed normal sinus rhythm without ST segment changes,
and echocardiography showed normal findings. A diagnosis of TTP was
made, and plasma exchange was rapidly initiated based on a plasma score
of 7 (severe). Methylprednisolone 1000 mg per day intravenously was
prescribed for three days. Due to increased serum amylase and
lipase levels, a computed tomography (CT) scan of the abdomen was
performed, which showed a swollen pancreas with fatty fibers around it
(Figure 2). An abdominal ultrasound showed the absence of radiolucent
stones. Subsequent laboratory tests ruled out hypercalcemia, and
hypertriglyceridemia as potential causes of pancreatitis. A CT scan of
the brain was normal. Based on the patient’s symptoms, cardiac troponin
I level was measured again, which was 1100 ng/ml. A consultation with a
cardiologist revealed that a non-ST-segment elevation myocardial
infarction had occurred. After three plasma exchanges, the patient’s
platelet count reached 52,000/L, and Tab Aspirin(ASA) and heparin were
started at a therapeutic dose. After the seventh session of plasma
exchange, the patient’s platelets reached more than 150,000/uL, and
after the eighth session, it was 190,000/uL. At the time of discharge,
it was 205,000/uL. The patient’s LDH also decreased to 446 U/L. Finally,
after eight sessions of plasma exchange and three days of
methylprednisolone and serum therapy, all the patient’s symptoms were
resolved, and the patient was discharged with Clopidogrel, ASA,
Atorvastatin, and oral Prednisolone 50 mg. The dose of prednisolone was
gradually reduced over four weeks.