Detection of left atrial compression by focused cardiac ultrasonography in a patient with worsening dyspnea
Thrombotic Thrombocytopenic Purpura, microangiopathic haemolytic anaemia, thrombotic events, multiorgan damage, plasmapheresis.
Thrombotic Thrombocytopenic Purpura (TTP) is an acute syndrome characterized by the presence of microangiopathic haemolytic anaemia and thrombocytopenia.
The first case of TTP was described by Moschowitz in 1924 . Recently, between 1982 and 2001, several authors [2-5] identified in the deficiency of the metalloproteinase ADAMTS13 the primary pathogenic cause. TTP is a rare disease [6-8]. it occurs between 30 and 50 years of age, more frequently in the female sex. In the absence of treatment, mortality exceeds 90%, while it is reduced to 10-20% after adequate plasma plasmapheresis or infusion therapy. However, half the deaths are attributable to complications associated with plasmapheresis and hospitalization (sepsis, haemorrhages, thrombosis, etc.) 
A 62-year-old man with history of gastric cancer presented to our Emergency Department (ED) with progressive dyspnea and reduced exercise tolerance during last weeks. At admission blood pressure was 110/70 mmHg, heart rate 70 beats/minute regular, oxygen saturation was 98% (FiO2 21%) with mild tachypnea (22 Breaths per minutes) and he was afebrile. Chest examination revealed decreased vesicular murmur in the base of left lung. Cardiovascular examination revealed a normal cardiac rhythm, no murmurs, normal peripheral pulses and no edema. Arterial blood gas analysis on room air revealed respiratory alkalosis with mild hypoxemia. The ECG showed sinus rhythm with normal AV conduction, normal axis and QT interval.
Results of blood tests showed a normal white blood cell count (6.660 cells per mm3), with renal and liver function test and serum electrolytes within the reference limits.
Focused cardiac ultrasonography (FoCUS) showed normal left ventricular (LV) size and function with annuloaortic ectasia and compression of left atrium (LA) due to a large mass englobing the descending aorta (DA) (Figure 1). Lung ultrasonography (LUS) revealed bilateral A-line pattern.
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