Correct!
6. All of the above

Six hours later, the patient’s GCS decreased to eight. A repeat CT scan showed enlargement of the hematoma to 10x6x6cm with extension into the lateral and fourth ventricles (Figure 1).

Figure 1. CT of the head at the time of admission and repeat CT six hours later.

The repeat platelet count was 118 x 10³/uL, INR 1.7, and fibrinogen 99 mg/dL. Platelets, FFP and cryoprecipitate were again transfused. An epsilon-aminocaproic acid bolus and infusion were started. The patient was intubated and taken to the operating room for decompression of the hematoma.

Our laboratory’s automated hematology analyzer triggered a reflex manual peripheral blood smear review of the admission CBC. An amended manual differential was reported on the morning of the second hospital day, noting 44% atypical mononuclear cells of unclear lineage, favored to be immature monocytes. No schistocytes were noted. A clinical diagnosis was made, diagnostic tests ordered and specific therapy emergently administered.

Which of following hematological emergencies is most likely  in this patient? (Click on the correct answer to be directed to the fourth of six pages)

1. CNS leukostasis due to acute myelogenous leukemia.
2. Hyperviscosity syndrome due to multiple myeloma.
3. Thrombotic thrombocytopenic purpura related to surreptitious use of clopidogrel.
4. Stroke due to delayed heparin-induced thrombocytopenia.
5. Fibrinolytic DIC secondary to acute promyelocytic leukemia (APL).

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