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A 65-year old man developed anaemia, profound thrombocytopenia and acute renal failure 2 days after transurethral resection of the prostate. Based on the clinical picture and blood film evidence of microangiopathic haemolysis, thrombotic thrombocytopenic purpura was diagnosed. The patient was treated with a course of plasma exchange, renal replacement therapy and methylprednisolone and made a good recovery. Thrombotic thrombocytopenic purpura is an uncommon cause of haematological and renal abnormalities in the postoperative period. It has a high mortality if untreated, and should be considered in the differential diagnosis of any postoperative patient with a low platelet count and anaemia, since prompt investigation and treatment is life-saving. Thrombotic thrombocytopenic purpura (TTP) is a microangiopathic haemolytic anaemia (MAHA) originally characterised by Moschowitz in 1925 [1], who described a febrile illness associated with hyaline thrombi in many organs. TTP was subsequently redefined as a pentad of thrombocytopenia, MAHA, renal impairment, fever and mental state changes [2]. It may be congenital or acquired due to a variety of causes (Table 1), and is classically considered part of a spectrum of disease with the haemolytic-uraemic syndrome (HUS). Most cases are associated with an ultra-large von Willebrand factor protein in the plasma (ULvWF), which promotes platelet aggregation and thrombotic occlusion of the microcirculation. In normal individuals ULvWF is cleaved into smaller, less thrombogenic forms of vWF by a protease, ADAMTS13 [3]. Patients with familial TTP have constitutionally low levels of ADAMTS13, while many patients with acquired TTP produce an inhibitory antibody to this protein [4,5]; in either case, the net effect is an increased level of circulating ULvWF. Patients with HUS do not share this defect, suggesting that quite different pathogenic mechanisms may be at work despite the clinical overlap.TTP classically occurs in adults and is often accompanied by mental state changes while HUS is seen in children with renal impairment; in practice there is considerable clinical overlap, with up to 35% of patients with TTP having no neurological abnormality at presentation [6]. The underlying pathological process in TTP may compromise the function of any organ, and patients may develop acute pancreatitis, flash pulmonary oedema, renal failure and a range of neurological changes from headache to fits and coma. The presence of MAHA and thrombocytopenia in an adult patient without an alternative cause is sufficient to make a diagnosis of TTP, regardless of the presence or extent of neurological or renal impairment [7]. Case reportA 65-year-old man with obstructive urinary symptoms underwent elective cystoscopy and transurethral resection of the prostate (TURP) under spinal anaesthesia. The procedure lasted 1 h and was without complication. Subsequent histology showed moderately differentiated adenocarcinoma. Prior to surgery the patient was apparently fit and well, taking no medication other tha...

We report the case of a 76-year-old man of the Jehovah's Witness faith who had a giant abdominal aortoiliac aneurysm that was successfully operated on using an aortoiliac Y-graft bypass technique, without the use of stored allogenic blood. Cell saver technique and recombinant human erythropoietin (epoetin beta) were used during the perioperative period. The patient had good postoperative care with a multidisciplinary approach.