26313770 Visualization

This is a 53 Age - year Age - old Age male Sex patient who went Clinical_event to our hospital Nonbiological_location with chief complaint of massive Severity gum Biological_structure bleeding Sign_symptom for 1 Duration day Duration .
The patient had a history of chronic Detailed_description hepatitis Disease_disorder C.
PEG Medication - IFN Medication -α-2a ( 180 Dosage   μg Dosage ) plus ribavirin Medication ( 1200 Dosage   mg/day Dosage ) were prescribed to the patient since Duration March Duration 17, Duration 2014 Duration .
He denied History any History autoimmune History conditions History before treatment.
The baseline virological Diagnostic_procedure data Diagnostic_procedure revealed high Lab_value virus Diagnostic_procedure load Diagnostic_procedure ( HCV Diagnostic_procedure RNA Diagnostic_procedure 2.1 Lab_value   × Lab_value   106 Lab_value   IU/mL Lab_value ) with genotype Diagnostic_procedure 1b Lab_value .
Rapid Detailed_description virological Sign_symptom response Sign_symptom was not achieved at the fourth Date week Date ( HCV Diagnostic_procedure RNA Diagnostic_procedure : 2.12 Lab_value   × Lab_value   106 Lab_value   IU/mL Lab_value ).
Partial Detailed_description early Detailed_description virological Sign_symptom response Sign_symptom ( HCV Diagnostic_procedure RNA Diagnostic_procedure : 103 Lab_value   IU/mL Lab_value at week Date 12 Date ) and delayed virological response ( HCV Diagnostic_procedure RNA Diagnostic_procedure : <15 Lab_value   IU/mL Lab_value at Week Date 24 Date ) were noted.
However, fatigue Sign_symptom , anemia Sign_symptom , and depression Sign_symptom syndrome Sign_symptom were progressed at 30th Date week Date .
The patient requested to stop treatment Medication at Week Date 36 Date .
The viral Diagnostic_procedure load Diagnostic_procedure at the end Date - of Date - treatment Date ( EOT Date ) was undetectable Lab_value .
The platelet Diagnostic_procedure count Diagnostic_procedure at EOT Date was 92 Lab_value   × Lab_value   103 Lab_value   cells/μL Lab_value and elevated Lab_value to 159 Lab_value   × Lab_value   103 Lab_value   cells/μL Lab_value 1 Date week Date later Date .
Two Date weeks Date following Date EOT Date , the patient developed massive Severity gum Biological_structure bleeding Sign_symptom .
The physical Diagnostic_procedure examination Diagnostic_procedure showed the multiple Quantitative_concept petechiae Sign_symptom on the extremities Biological_structure .
There is no sign of intracerebral Biological_structure hemorrhage Sign_symptom , gastrointestinal Biological_structure bleeding Sign_symptom , or other internal bleeding.
The initial Detailed_description platelet Diagnostic_procedure count Diagnostic_procedure was 4 Lab_value   × Lab_value  103cells/μL.
Coagulation Diagnostic_procedure profile Diagnostic_procedure showed normal Lab_value prothrombin Diagnostic_procedure time Diagnostic_procedure , activated Diagnostic_procedure partial Diagnostic_procedure thromboplastin Diagnostic_procedure time Diagnostic_procedure , fibrinogen Diagnostic_procedure , d Diagnostic_procedure - dimer Diagnostic_procedure , and fibrin Diagnostic_procedure degradation Diagnostic_procedure product Diagnostic_procedure .
Peripheral Diagnostic_procedure blood Diagnostic_procedure smear Diagnostic_procedure showed neither fragmented Sign_symptom red Sign_symptom blood Sign_symptom cells Sign_symptom , helmet Sign_symptom cells Sign_symptom nor abnormal Sign_symptom platelet Sign_symptom aggregation Sign_symptom .
Concomitant autoimmune connective Disease_disorder tissue Disease_disorder diseases Disease_disorder such as systemic Disease_disorder lupus Disease_disorder erythematosus Disease_disorder or cryoglobulinemia Disease_disorder were excluded due to negative Lab_value anti Diagnostic_procedure - nuclear Diagnostic_procedure antibody Diagnostic_procedure and cryoglobulin Diagnostic_procedure except for positive Lab_value anti Diagnostic_procedure - cardiolipin Diagnostic_procedure IgG Diagnostic_procedure ( 116 Lab_value GPL Lab_value , normal range <20 GPL) and anti Diagnostic_procedure - phospholipid Diagnostic_procedure IgG Diagnostic_procedure ( 165 Lab_value   U Lab_value , normal range <15 U).
Anti Disease_disorder - phospholipid Disease_disorder syndrome Disease_disorder was excluded due to no History previous History thromboembolic History events History , according to 2006 Detailed_description Sapporo Diagnostic_procedure criteria.12 Bone Biological_structure marrow Biological_structure biopsy Diagnostic_procedure was also performed, which revealed hypocellular Sign_symptom marrow Biological_structure with even Lab_value cellular Diagnostic_procedure distribution Diagnostic_procedure and without evidence of lymphoid Disease_disorder neoplasia Disease_disorder .
The potential drugs Medication that Medication may Medication cause Medication platelet Medication lysis Medication were ruled out.
Blood Therapeutic_procedure transfusion Therapeutic_procedure of platelet was performed, but poor Lab_value response Diagnostic_procedure with rapid Lab_value decline Lab_value of platelet Diagnostic_procedure count Diagnostic_procedure in the next Date day Date of transfusion Therapeutic_procedure .
A diagnosis of immune Disease_disorder thrombocytopenic Disease_disorder purpura Disease_disorder was made.
We started intravenous Administration methylprednisolone Medication therapy ( 40 Dosage   mg, Dosage 3 Dosage times Dosage daily Dosage ) on November Date 27 Date combined with platelet Therapeutic_procedure transfusion Therapeutic_procedure treatments Therapeutic_procedure .
It still showed no significant improvement Sign_symptom .
Azathioprine Medication ( 100 Dosage   mg Dosage , oral Administration , once Dosage daily Dosage ) was added since Date December Date 3 Date .
Hydroxychloroquine Medication ( 400 Dosage   mg Dosage , oral Administration , once Dosage daily Dosage ) was also prescribed due to positive Lab_value anti Diagnostic_procedure - phospholipid Diagnostic_procedure antibodies Diagnostic_procedure .
Platelet Diagnostic_procedure count Diagnostic_procedure gradually increased Lab_value to 93 Lab_value   × Lab_value   103 Lab_value   cells/μL Lab_value 17 Date days Date after Date admission Date , so methylprednisolone Medication was changed to oral Administration form and slowly tapered Dosage off Dosage .
On December Date 15 Date , the patient was discharged Clinical_event due to stable Sign_symptom condition Sign_symptom with platelet Diagnostic_procedure counts Diagnostic_procedure elevating Lab_value to 117 Lab_value   × Lab_value   103 Lab_value   cells/μL Lab_value (Figure ​1).
Followed laboratory Diagnostic_procedure data Diagnostic_procedure after Date 5 Date months Date revealed sustained Detailed_description virologic Sign_symptom response Sign_symptom , platelet Diagnostic_procedure count Diagnostic_procedure above Lab_value 150 Lab_value   × Lab_value   103 Lab_value   cells/μL Lab_value , and decreased Lab_value anti Diagnostic_procedure - cardiolipin Diagnostic_procedure IgG Diagnostic_procedure ( 30.5GPL Lab_value ) and anti Diagnostic_procedure - phospholipid Diagnostic_procedure IgG Diagnostic_procedure ( 73.21 Lab_value   U Lab_value ) levels.