#00063965

A 36-year-old male patient presented with fever, gum bleeding and dyspnea on exertion for 2 weeks and subsequently diagnosed as acquired aplastic anemia (very severe) with pending investigation for stress cytogenetics. Allogenic stem cell transplant was not an option as he had no siblings. So initial treatment by immuno-suppressive therapy was planned with supportive measures. But within next few days he had persistent high-grade fever with bleeding manifestations and was managed as febrile neutropenia with multiple antibiotics, antifungals empirically and also as per culture and sensitivity reports. Despite of these he was running persistent high-grade fever. The only organism isolated was Klebsiella pneumoniae from an ulcer in the oral cavity which was not an multi drug resistant. In due course he developed a hemorrhagic blister over the dorsum of his left hand, wrist and forearm (figure) within one overnight period. He also developed hypotension and drop in urine output in the mean-time. Investigations showed hemoglobin 5.4 gm/dl, total leucocyte count 130/mm3 , platelet 4000/mm3 , prothrombin time 17.2 sec with control 11.1 sec and INR 1.55, aPTT 41.3 sec with control 27.3 sec, serum urea 57 mg/dl, creatinine 1.92 mg/dl, total bilirubin 1.88 mg/dl, direct bilirubin 1.86 mg/dl, SGOT 170 U/l, SGPT- 102 U/l, LDH 348 U/l, CRP 22.3 mg/dl, fibrinogen 105 mg/dl and D-dimer was 2900 ng/ml. ISTH DIC score was 6, indicating an overt DIC. He received fresh frozen plasma transfusion. Then he within next 4 hours needed vasopressor and mechanical ventilator support and ultimately succumbed to sepsis.