Thrombotic Thrombocytopenic Purpura or Disseminated Intravascular Coagulation?

Sir,

We read the paper by Gavali et al., concerning a case of dengue virus infection complicated with thrombotic thrombocytopenic purpura (TTP) with interest.[1] Perhaps, however, disseminated intravascular coagulation (DIC) should have been ruled out in that setting.

Complex thrombohemorrhagic disorders refer to the group of conditions with heterogeneous clinical presentation ranging from bleeding to microvascular and macrovascular thrombosis, and DIC and TTP/hemolytic uremic syndrome (HUS) are common examples.[2]

Both these disorders are difficult to diagnose due to similar and heterogeneous clinical presentations as well as the lack of specific laboratory tests and specific diagnostic criteria. Schistocytes, thrombocytopenia and elevated lactate dehydrogenase occur in both conditions, however, usually more marked in TTP/HUS.[2]

In patients with suspecting TTP/HUS, laboratory investigation should be done to rule out DIC (clotting screen including fibrinogen) and to evaluate evidence of microangiopathic hemolytic anemia (total and indirect bilirubin, reticulocyte count, lactate dehydrogenase, haptoglobin, and direct antiglobulin test), especially in conditions where DIC is much more likely than TTP/HUS (like in dengue and many other infections).[34]

In the absence of sufficient investigations to support, the diagnosis of TTP in the index case is uncertain. Improvement in the clinical features and laboratory parameters are typical of recovery phase in dengue and therefore should not be considered as a result of specific treatment of TTP in this setting.

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Conflicts of interest

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