Thrombotic thrombocytopenia purpura (TTP) in the background of systemic lupus erythematous (SLE) remains rare with an incidence of about 2%. Both conditions have overlapping features and can thus be difficult to differentiate and diagnose. A careful review of the peripheral blood smear remain essential often providing many clues. The diagnosis of TTP is a medical emergency and therapy should be instituted immediately. We present one such challenging case where a delay in diagnosis due to limited resources could have proven fatal for our patient.