Thrombotic Thrombocytopenic Purpura

A 23-year-old medical student who had rheumatoid spondylitis had been given a series of injections of penicillin-procaine intramuscularly on several occasions. He had received 300,000 units daily from January 3, 1950, to January 16, 1950, and from February 16, 1950, to March 2, 1950. The only untoward reaction at this time was mild local induration at the injection sites. He again received intramuscular injections of 300,000 units of penicillin-procaine daily from September 22 to September 24, 1950, and from October 31 to November 2, 1950. On June 3, 1952, a course of 1,000,000 units of penicillin-procaine daily was begun. After the injection on June 5 the patient noticed an immediate mild reaction, which consisted of mild nausea and excessive salivation. Penicillin was discontinued at this time. On June 10, coincident with administration of diphenhydramine by mouth, generalized pruritic, macular rash developed and then faded in two days. Because an aortic systolic murmur had been noted previously, it was decided to administer penicillin prophylactically in preparation for removal of chronically infected tonsils. Accordingly, an aqueous solution containing 600,000 units of penicillin 0 was administered intramuscularly on June 17. Approximately three minutes after the injection the patient felt a sensation of tingling throughout his entire body. At the same time he had an urge to defecate, felt substernal oppression, and noted increasing dyspnea and a copious flow of saliva, which drooled to the floor. Within about two minutes his vision became blurred, and he lost consciousness. Upon examination the patient was observed to be diffusely flushed, sweating, and breathing with obvious difficulty. He was drooling large amounts of tenacious mucoid material. Breath sounds were distant, and no wheezing was observed. Radial pulsation could not be felt and the blood pressure was unobtainable, although the heart sounds were not abnormal. Epinephrine, 0.5 ml., was administered subcutaneously and repeated twice at intervals of 10 minutes. Diphenhydramine, 5 mg., was administered intravenously. The status of the patient seemed to improve slightly following the initial dose of epinephrine and diphenhydramine, but the pulse was impalpable until shortly after plasma was given intravenously. At this time the blood pressure rose gradually, and consciousness returned. The patient awoke with a sensation of vise-like retrosternal oppression and dyspnea, especially on inspiration, although respirations at this time appeared only slightly labored. He vomited approximately 1,500 ml. of clear, tenacious mucoid material. The patient then improved rapidly, and when admitted to the University of California Hospital three hours later was essentially asymptomatic. No abnormalities were noted upon physical examination at that time. The blood pressure was 120/80 mm. of mercury. Leukocytes numbered 14,750 per cu. mm. of blood78 per cent polymorphonuclear cells, 2 per cent eosinophils, 9 per cent lymphocytes and 11 per cent monocytes. Two days later when the patient was discharged from the hospital as recovered, leukocytes numbered 6,300 per cu. mm. with 35 per cent polymorphonuclear cells, 34 per cent eosinophils, 2 per cent basophils, 22 per cent lymphocytes, and 7 per cent monocytes. The results of urinalysis were normal. No intradermal test for sensitivity to penicillin was carried out because of fear of reaction.