Author: Tay Xue Chao Brian Diaz / Editor: Sarah Edwards / Codes: HP1, HP2, ObC17, SLO1 / Published: 05/05/2021

A 42-year-old lady who is 35 weeks pregnant is brought into your department by her husband. He reports that she started having diarrhoea about 7 days ago, but has now also developed confusion, fever, and widespread bruises despite the absence of trauma.

On general examination, she appears unwell.

  • Airway: Patient.
  • Breathing: Equal and good air entry bilaterally. Respiratory rate 25. Oxygen saturations on room air 96%.
  • Circulation: Heart sounds normal. Capillary refill <2 seconds. Heart rate 120. Blood pressure 130/80.
  • Disability: GCS 14 as she is mildly confused and does not know where she is. She does not have any neck stiffness, photophobia, or any other signs of meningeal irritation. Formal neurological examination reveals no abnormalities.
  • Temperature: 38 Degrees Celsius.
  • Exposure: Her abdomen is soft and is in keeping with the pregnancy.

There is a widespread purpuric rash and ecchymosis. The picture below is of her legs.

Fig.1

Bloods and cultures were taken at triage.
Laboratory results:
Haemoglobin: 8 g/dL
White cell count: 12 x 10^9/L
Neutrophils: 7 x 10^9/L
Platelets: 55 x 10^9/L

Prothrombin time (PT): 14 seconds (10-14 seconds)
Activated partial thromboplastin time (APTT): 35 seconds (24-37 seconds)
Fibrinogen: 3.10 g/L (1.50-4.50 g/L)
D-dimer: 180 ng/mL (<300 ng/mL)

Na+: 140 mmol/L
K+: 4.5 mmol/L
Urea: 26 mmol/L
Creatinine: 320 umol/L

pH: 7.25
Lactate: 4.3
Glucose: 8 mmol/L
Urine dip shows 3+ protein and 1+ RBC. Leukocytes and nitrites are negative.
The laboratory has taken the liberty of doing a peripheral blood smear. Schistocytes are present.

Fig.2

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