Abstract
<title>Abstract</title> <p>This case demonstrates that when COVID-19 coagulopathy, septic shock, and thrombotic microangiopathy overlap, the classic signs of thrombotic thrombocytopenic purpura (TTP) may be obscured-yet timely recognition and treatment are lifesaving. Despite the patient’s active COVID-19 infection, multifocal cerebral infarctions, thrombocytopenia, microangiopathic hemolytic anemia (elevated LDH, low haptoglobin, reticulocytosis), and near-normal coagulation studies (PT/INR) pointed away from disseminated intravascular coagulation and toward TTP. Notably, the peripheral smear showed only slight schistocytosis, a potential pitfall that should not delay suspicion. The critical “cure” was confirming severe ADAMTS13 deficiency (0.013%) and promptly initiating therapeutic plasma exchange, corticosteroids, and supportive care. Even after five days of plasma exchange, hemoglobin and platelets improved and LDH declined, allowing recovery from respiratory failure and renal failure requiring dialysis. The key lessons are: (1) Do not rely solely on schistocyte count to exclude TTP in critically ill COVID-19 patients; (2) near-normal PT/INR with unexplained hemolysis and thrombocytopenia should raise TTP suspicion; (3) while awaiting ADAMTS13 results, early plasma exchange can be life-saving; and (4) COVID-19-associated hypercoagulability and TTP can coexist, and the former does not rule out the latter. Delayed access to ADAMTS13 testing is a common barrier, but high clinical suspicion and prompt empiric plasma exchange remain the definitive “cure” for preventing irreversible neurologic injury and death.</p>