A 33-year-old female presented to our Emergency Department (ED) because of hypertensive crisis with Headache and blurred vision. She had been having progressive shortness of breath over 6 Months that worsened acutely on the admission day with no significant past medical history. The patient was as she arrived the ED, aggressive and that is she directly be intubated. She was afebrile. An electrocardiogram was performed, which showed sinus rhythm with a left ventricle hypertrophy, Sokolow index was 43 mm. This Patient has a hs-TNI at 33490 ng/dl, 4 hours after the admission (normal 2.3-11.6 ng/l), at the admission was only 420 ng/l Coronary angiogram was without a significant epicardial coronary artery disease. For further evaluation we measured the microcirculatory resistance (IMR=72) and coronary flow reverse (CFR =1.2) which were pathologic.

An arterial blood gas showed the following results: pH 7.4 (normal 7.35-7.45), pO2 328 (normal 71-104 mmHg) pCO2 43 (normal 37-43 mmHg), bicarbonate 25.9 (normal 22-26 mmol/L), lactate 1.4 (normal 0.5-2.5 mmol/L), sodium 133 (normal 134-144 mmol/L), potassium 2.7 (normal: 3.5-5.5 mmol/L). Laboratory evaluation revealed markedly elevated creatinine level at 3.5 (normal: 0.7-1.1 mg/dl), the Hemoglobin was 111 g/l (normal 120-160 g/l) with Thrombocytopenia (43 /nl (normal 150-400 /nl), the haptoglobin was low <0,20 (normal 0,30-2,0 g/l), elevated LDH 702 (normal rang <250 U/l).

Considering the above we have laboratory values ​​to suspect TTP (thrombotic thrombocytopenic purpura), in laboratory diagnostics we saw low haptoglobin and increased LDH, for further diagnostics we determined functional protease (ADAMTS13), this was low. SLE could be ruled out with laboratory tests.

In the first cMRI showed a suspected PRES from the brainstem to the medulla oblongata with multiple marrow medullary lesions, from those was some are morphologically associated with chron. inflammatory CNS disease. Suspected supratentorial cerebral edema. No other lesions in the cervicothoracic spinal cord. In the second cMRI showed In comparison to the preliminary examination, declining diffusion restriction on the centrum semiovale bilaterally and in the splenium corpus callosum, most likely transient reversible cytotoxic edema. Using CT/thorax and abdomen, we did not see any definable focus of infection in the thoracoabdominal region. Suspicion of increased mediastinal lymph nodes without clearly pathological enlargement. The Echocardiographic showed the picture of a hypertrophic non-obstructive cardiomyopathy.