A 26-year-old woman presented with gradual loss of vision, gingival bleeding and fatigue over the previous three weeks. Visual acuity was counting fingers in the right eye and 20/200 in the left. Ophthalmoscopy revealed severe, intraretinal hemorrhage with preretinal hemorrhage obscuring the optic nerve head in each eye. Fluorescein angiography confirmed normal transit times. There was no nonperfusion, vasculitis or neovascularization.
Her hematocrit was 14 percent, platelets were 12 K/mm3 and white cell count was 25 K/mm3. Bone marrow biopsy was negative for malignancy. ANA testing was positive at 1:2,560, but double-stranded DNA antibody, lupus anticoagulant and anticardiolipin antibodies were negative. MRI was normal. A presumed diagnosis of immune thrombocytopenic purpura was made and she was treated with blood transfusions, SoluMedrol, immunoglobulins and rituximab. On follow-up, her vision improved to 20/800 in the right eye and 20/70 in the left eye. Unfortunately, her thrombocytopenia could not be reversed and she died of a massive intracranial bleed one month after presentation. Written by Sangeeta Khanna, MD, and Bradley T. Smith, MD, both of Washington University in St. Louis. Blink is edited by Richard E. Hackel, MA, CRA, FOPS.
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