ABSTRACT
Background: Up to 23-25% of patients experience a second stroke within the first 5 years after the first episode despite prophylaxis. Aim(s): Our aim is to discuss the risk factors of recurrent ischemic stroke and the efficiency of anticoagulation therapy. Method(s): A report of a 50-year- old female patient who presented with a medical history of migraine, hypertension, 3 episodes of ischemic stroke within 12 years (the last one occurring 2 months ago), right hemiplegia, 2 miscarriages and multiple surgeries: appendectomy, myomectomy, hysterectomy due to adenomyosis, cataract surgery, cervical polypectomy, oophorectomy, meniscectomy after trauma. Result(s): Thrombophilia testing revealed heterozygous mutations of F13A1, ITGA2 and PAI1 genes. Antiphospholipid antibodies were within normal ranges. She received treatment with Rivaroxaban 20 mg/daily 1 month, B-Complex vitamins, after which Clopidogrel 75 mg was prescribed. But the next ischemic stroke with hemorrhagic transformation occurred within 6 months. Type 2 diabetes was diagnosed 1 year later and Metformin hydrochloride was initiated. She underwent cholecystectomy due to benign tumors of the gallbladder and received treatment for Helicobacter pylori after which fifth episode of ischemic stroke happened. One year later she complained of headache, dizziness, unsteady gait, memory impairment, syncope and convulsions. Electroencephalography and echocardiography findings were not remarkable, ultrasound revealed multinodular goiter (TIRADS 2). COVID-19 PCR test and anti-SARS- CoV- 2 IgG/IgM antibodies were negative. Labs showed 40.9% lymphocytes, prolonged APTT (45.4 s, reference range 30-40 s), slightly elevated ALT (34.9 U/L, reference range < 33). Urinalysis detected 0.03 g/L albumin and 1.13 HPF mucus. Two weeks later the sixth episode of ischemic stroke occurred despite receiving antiaggregation with Acetylsalicylic acid. Double testing for antiphospholipid antibodies, Protein C and S, homocysteine were normal, antithrombin III was 123.0%. Conclusion(s): Although low-risk thrombophilia mutations, type 2 diabetes, hypertension, overweight and multiple surgeries are the risk factors of 6 thrombotic events, cancer should be excluded taking into account her anamnesis.
ABSTRACT
Background: Immune hemolytic anemia (AIHA) and thrombocytopenia (ITP) may rarely coexist with autoimmune disorders. Primary IHA and ITP usually respond to steroids and intravenous immunoglobulins. However, IHA+ITP may be difficult to treat when associated with autoimmune disorders. Aim(s): We report a case of a 57-year- old man diagnosed with AIHA and ITP and also found to have thyroiditis. Method(s): A retrospective review of the patient's medical history was performed. Result(s): A 57-year- old- woman with bruises, weakness, fatigue, and dizziness was admitted to the hematology center. This time CBC test was revealed hyperchromic macrocytic anemia with anisocytosis, thrombocytopenia, lymphocytosis and high level of ESR. Coomb's reactions were positive. The patient had been on autoimmune thyroiditis for about 5 years and was receiving 50 mg of L-thyroxin. Laboratory testing revealed only slightly elevated LDH level in serum and no other significant abnormalities. Instrumental examination were also normal. Our differential diagnosis included TTP, Evans and marrow infiltrative disorders. Direct antiglobulin test positive (IgG, IgG + C3d). We made a diagnosis of immune hemolytic anemia and thrombocytopenia and started treatment with Prednisolone 65mg per day. In about six months Duplex scan showed acute thrombosis of right external iliac vein. October 2021. The patient was diagnosed with COVID-19, Bilateral interstitial pneumnonia. On the way home ischemic stroke occurred. Thrombectomy -within 12 h Conclusion(s): ITP can rarely coexist with thyroiditis and Thrombosis episode. In such cases, we involuntarily deviate from the contraindications of standard anticoagulant therapy, and, regardless of the low platelet count, administer anticoagulant therapy and combine it with steroid medication. The clinical case is evidence that the treatment of concomitant immune system disorders improves the course of treatment for all pathologies but poses a thrombotic complication.