Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jul 6, 2019; 7(13): 1660-1670
Published online Jul 6, 2019. doi: 10.12998/wjcc.v7.i13.1660
Gastrointestinal infection-related disseminated intravascular coagulation mimicking Shiga toxin-mediated hemolytic uremic syndrome - implications of classical clinical indexes in making the diagnosis: A case report and literature review
Xiang-Yang Li, Yan-Fen Mai, Jing Huang, Pearl Pai
Xiang-Yang Li, Yan-Fen Mai, Pearl Pai, Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
Jing Huang, Department of Hematology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
Pearl Pai, Department of Medicine, The University of Hong Kong - Queen Mary Hospital, Hong Kong, China
Author contributions: Li XY is the doctor-in-charge and conceived and wrote the manuscript; Mai YF is the attending doctor and collected the data; Huang J provided counseling and critical review; Pai P performed critical reviews and revisions.
Informed consent statement: Informed consent statements were obtained from the patients.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Pearl Pai, FRCP, PhD, Director, Doctor, Department of Nephrology, the University of Hong Kong-Shenzhen Hospital, 1st Road of Hai-yuan, Shenzhen 518053, Guangdong Province, China. ppai1@hku.hk
Telephone: +86-755-86913333 Fax: +86-755-86913108
Received: March 1, 2019
Peer-review started: March 4, 2019
First decision: April 18, 2019
Revised: April 26, 2019
Accepted: May 1, 2019
Article in press: May 1, 2019
Published online: July 6, 2019
Processing time: 126 Days and 23.2 Hours
Abstract
BACKGROUND

Thrombocytopenia associated with acute kidney injury is a challenging disorder. Thrombotic microangiopathy (TMA) is a potentially life- or organ-threatening syndrome that can be induced by several disorders or medical interventions. There is overlap between the clinical presentation and pathophysiology of thrombotic thrombocytopenia purpura and hemolytic uremic syndrome (HUS), and to a lesser extent, disseminated intravascular coagulation (DIC). We describe a case to illustrate the potential diagnostic difficulty, especially at initial presentation.

CASE SUMMARY

We reported a case of a 44-year-old woman that presented with diarrhea, thrombocytopenia, schistocytes, elevated serum lactate dehydrogenase (LDH) level and acute kidney injury. While the clinical presentation resembled that of Shiga toxin–induced HUS, the disease course was more consistent with gastrointestinal infection-related DIC. To aid in the accurate diagnosis of TMA and other associated disorders, we have undertaken a review and provided a clear interpretation of some typical biomarkers including schistocytes, LDH and platelet count, coagulation profile and more specific indexes of ADAMTS13, complement profile, and the isolation of Shiga toxin-producing Escherichia coli (commonly referred to as STEC).

CONCLUSION

The use and correct interpretation of classical indexes of schistocyte, LDH, and platelet count is vital in diagnosing TMA and associated disorders. Understanding the characteristics of these biomarkers in the context of thrombocytopenia purpura, HUS and DIC will facilitate the accurate diagnosis and early initiation of appropriate treatment.

Keywords: Thrombotic microangiopathy; Thrombotic thrombocytopenic purpura; Hemolytic uremic syndrome; Schistocyte; Lactate dehydrogenase; Thrombocytopenia; Case report

Core tip: Thrombotic microangiopathy is a severe and challenging disorder. There is overlap between the clinical presentation and pathophysiology of thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and disseminated intravascular coagulation. Upon literature review, we use a case study to illustrate the characteristics and utility of classical clinical indexes of schistocytes, lactate dehydrogenase, platelet count and coagulation profile in parallel with more specific investigations of ADAMTS13, complement profile, and isolation of Shiga toxin-producing Escherichia coli, in an attempt to facilitate the early recognition and diagnosis of thrombotic microangiopathy.