Immune Thrombotic Thrombocytopenic Purpura Presenting as an Acute Stroke Mimic in a Young Pakistani Man

Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy that can have acute neurological symptoms and resemble ischemic stroke. A 27-year-old Pakistani man was transported by ambulance after being found unconscious, unable to speak, and unable to move his right side, which was suspected to be a stroke. He had been unwell for two weeks, was clinically jaundiced, and had a possible seizure during the previous week. Urgent plain computed tomography (CT) and CT angiography of the brain were called and revealed no acute abnormality and no obvious large vessel occlusion. There was no evidence of acute infarction on magnetic resonance imaging. His National Institutes of Health Stroke Scale (NIHSS) score was 15/42, which is a moderate stroke. Laboratory studies showed hemoglobin 6.0 g/dL, platelet count 3x109/L, schistocytes on peripheral smear, lactate dehydrogenase 2139 U/L, haptoglobin <0.01 g/L, reticulocytosis, and mainly indirect hyperbilirubinemia. The clinical features were compatible with iTTP complicated with neurological involvement. The patient was treated with therapeutic plasma exchange daily, high-dose methylprednisolone, and rituximab. Platelets rose steadily to 199x109/L on day 8, bilirubin levels dropped to 14.2 µmol/L, and lactate dehydrogenase levels dropped to 259 U/L at discharge. Neurological recovery was quick, with resolution of the right-sided weakness by the fourth hospital day and an NIHSS score of 0. This case highlights that in young patients with stroke-like presentation, severe thrombocytopenia, and microangiopathic hemolytic anemia, prompt plasma exchange and immunosuppression can be lifesaving and should be considered in iTTP.