And to avoid an allergic reaction to the new plasma, the doctors also gave Ralph IV Benadryl before each plasma exchange treatment. Ralph remembers feeling "a chill sensation" during plasma exchange. Ralph was given a unit of red blood cells, 100 mg of prednisone (steroid) each day, and plasma exchange was done daily. The doctors worked hard to try to correct Ralph's blood problem. It was then that Ralph and Sherrie were introduced to doctors who not only knew about TTP, but they were able to explain and provide information about the disease. The next day Ralph was transported to a larger hospital in the city. They had no idea what they were dealing with, but they were about to live it out. Sherrie also remembers being told that the average course of this disease was two or three weeks. Sherrie and Ralph had no idea what that meant, and they felt that the doctors were just as ignorant of the disease as they were. Sherrie, Ralph's wife, remembers the doctor telling them that Ralph had TTP. The team from the city arrived at the intensive care unit at midnight to begin the plasma exchange. In the case of Ralph, the venous catheter was inserted into his subclavian vein (just below his right collar bone). The catheter is needed to pump fluids both in and out of the patient’s blood system. In order to do this, a surgeon was called in to put in a large diameter catheter into one of Ralph's large veins close to his heart. Plasma exchange is a procedure where a pump is used to pull out the plasma (liquid part of the blood) and the cells are returned with an equal amount of fresh frozen plasma (FFP) obtained from normal donors. It was felt that this was the quicker way to begin this potentially life-saving treatment, rather than transferring Ralph to a city hospital. Treatment with plasma exchange was planned to begin that Sunday evening by sending a team to the hospital where Ralph was. After further telephone discussion with a hematologist, the diagnosis of TTP was confirmed by the presence of severe thrombocytopenia (low platelets) and hemolytic anemia (anemia caused by the destruction of red blood cells) in association with neurologic (Ralph's trouble was with his memory) and kidney abnormalities (increased blood level of creatinine, a chemical normally excreted by the kidneys). And from this information, the blood center doctor was able to suggest the possibility of a rare disease known as TTP (thrombotic thrombocytopenic purpura). The ER doctors described the symptoms and lab results, which they could not figure out. When the hospital called the regional blood center to restock the platelets that had been administered, a doctor at the blood center called the doctors at the distant emergency room to ask why they had given two platelet transfusions to Ralph. With the order of the platelet transfusions came a stroke of luck. Ralph remembers being "scared to death by the reaction of the doctors around me." The doctors decided to give Ralph a platelet transfusion, and then another. Other lab tests showed that his platelets were 2,000 (normal is over 150,000), and his LDH (an enzyme in the blood plasma increased LDH levels indicate damage to red blood cells and other tissues) was greater than 2,000 (normal is less than 200). He remembers, "Blood was coming from everywhere!" His CBC (complete blood count) showed that his hematocrit was 32% (hematocrit is a measure of the number of red blood cells, normal is over 41%). He had blood in his stool and urine samples. Upon arrival at the emergency room, Ralph began to experience trouble with his memory. Once at the clinic the physician did a blood test, which revealed a severely low platelet count he directed Ralph to go immediately to the local hospital emergency room. And with the exception of aspirin, he was not taking any medications. He complained only of pain in his belly and exhaustion he did not have any nausea, vomiting, diarrhea, fever, or cough. This stomach ache advanced over the course of three days, until Sunday evening when he and his wife, Sherrie, made the decision to visit the 24 hour clinic. Throughout that Friday the exhaustion persisted, and Ralph began to develop a stomach ache. But on this Friday morning, he recalls, "I was barely able to shave and I was too tired to even shower." Ralph called in sick and decided to rest. Ralph arose and attempted to begin his daily routine of preparing himself for the workday. By the next morning the feeling of being tired had developed into exhaustion and a total lack of energy. But this time it felt different to this slightly overweight, yet active, middle-aged man. As a member of the law enforcement community, working hard and feeling tired were not abnormal. On a Thursday evening in September, Ralph noticed that he was feeling a little more tired than usual. Severe TTP with a Prolonged Four Month Course in a Middle-Aged Man
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