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Recurrent Thromboembolism, Adenocarcinoma and Antiphospholipid Syndrome

Case Report A 54-year-old hypertensive man suddenly developed left hemiparesis (arm II/V, leg IV/V) and left homonymous hemianopia. After intravenous t-PA at 2 h after the onset of symptoms, the hemiparesis improved to IV/V. An MRI taken 5 days later revealed an infarct in the right middle cerebral artery (MCA) territory (fig. 1a). MR angiogram, EKG and transthoracic/transesophageal echocardiogram findings were normal. He was treated with antiplatelets. Two weeks later, his left hemiparesis worsened to III/V, and the CT scan showed enlarged MCA territory infarction. He was then treated with warfarin with the international normalized ratio (INR) maintained at 2.0– 3.0. One month later, he developed deep vein thrombosis in the legs. Laboratory results showed a positive lupus anticoagulant (LA) test, anticardiolipin (aCL) IgG 21.9 GPL/ml (normal !18 GPL/ml) and protein C 24% (normal 70–140%). aCL IgM, free protein S and total protein S levels were within normal imits. Despite increasing the warfarin dose (INR value 13), the deep vein thrombosis did not improve. Four months later he developed blindness, confusion and aggravated left-sided weakness. Repeat MRI showed enlarged previous right MCA infarction, and diffusion MRI identified new infarcts in the scattered area of both hemispheres (fig. 1b). Four months later he had aggravated leg edema and pulmonary embolism, when the INR was 2.76, LA was positive and aCL IgG was 21.4 GPL/ ml. The protein C level was normalized. Four months later, the chest X ray revealed numerous, disseminated nodular lesions in both lungs. A biopsy on the right supraclavicular lymph node revealed findings consistent with metastatic adenocarcinoma (fig. 2). The patient expired 2 weeks later.