55 year female patient presented to casuality  on 28^th of may 2019 at 1am with complaints of:

 Breathlessness since a week which progressed from grade 2 to grade 4

Fever of low grade since 1week associated with loss of appetite.

Dark coloured stools since 1 day (1 episode)

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back then developed fever of low grade ,not associated with chills and rigors ,continuous type, subsiding with medication,breathlessness was insidious in onset ,gradually progressed from grade 2 to grade 4 interfering with her routine activity,following which patient was taken to nearby hospital and routines were advised.

Blood picture showed pancytopenia picture with a very low hb and platelet count in view of which patient underwent 2 packed RBC and 2 platelet transfusions in a span of 1 week,post transfusion there was a transient increase in platelet count (five fold from baseline) but again there was a drastic fall to the baseline 

Now the patient presented to us with breathlessness,

On examination:

Respiratory system:

on auscultation: End inspiratory crepts were present.

No other positive findings

Other systems: NAD

 Ordered for all the routines:

Hemogram: bicytopenia picture.
                    HB 6.2
                    Total count    7800
                    platelet count 8000

stool for occult blood  positive 

2decho was normal.

ecg was normal

PROVISIONAL DIAGNOSIS:  ? NEWLY DIAGNOSED IMMUNO THROMBOCYTOPENIC 

As the patient dint had any bleeding manifestations ,she was only put on observation(watch and wait) and had planned her for bone marrow examination the next day.

AT 7pm: patient had cough after which she developed deviation of angle of mouth towards left associated with loss of speech ,intracranial bleed was suspected and ct brain was advised.

CT brain  showed left sided chronic subdural heamotoma involving parietotemporal convexities.

On examination :

GCS  E4 M4 V 1

pupils were reacting to light with conjugate deviation towards the side of lesion.

Tone decreased in all the limbs.

Power:

RIGHT	LEFT
UL                             LL	UL                             LL
1/5                           2/5	4/5                           4/5

Reflexes:                Absent in all the limbs

                 Plantar         Rt                              Lt

                                   Mute                      Flexor

Acute event was strongly suspected and planned for MRI brain .

MRI brain revealed : 

30^th MAY:

Repeat CBP’s showed downward trend in the platelet count and also she was developing purpura over limbs and petechiae over the oral mucosa,1 pack of platelets were transfused and  started her on

High dose dexamethasone 40 mgs  ,continued it for 5 days but then it showed no improvement constantly her platelet count was on lower side rather there was a hike in her total leucocyte count.

patient was having fever spikes ,as we werent unable to locate for the source of infection, urine microscopy was advised and blood and urine cultures were sent.

Just emperically started the patient on INJ piptaz, but this dint serve the purpose and there was constant increase in total count.

 After obtaining culture reports started her on INJ  AMIKACIN.

The patient was deteriorating, her GCS was gradually declining ,despite 2 platelet transfusions and high dose steroids patient dint show any improvement.

On 4th of MAY : planned for repeat CT brain as the patient GCS was declining

5th of may : As the patient status was worsening ,in view of low GCS patient was intubated and put on ventilator on ACMV mode 

Currently patient is struggling between life and death, 

We are really not sure whether antiplatelets to be initiated or not ,if to be started how  far will it help in this patient with high risk of bleeding tendencies.