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An interesting case of hyperhomocysteinemia presenting as acute myocardial infarction and cerebral venous thrombosis

When a young patient presents with ischemic stroke or recurrent venous thromboembolism of unknown aetiology or “young” myocardial infarction in the absence of traditional risk factors, a detailed thrombophilia workup becomes an imperative. In a setting of arterial and venous occlusive disorders hyperhomocysteinemia is an important risk factor in the absence of traditional contributory aetiologies. Here we present a case of 28-year-old man, never-smoker with no known comorbidities who initially presented to the hospital with acute, retrosternal chest pain, radiating to the left side. His ECG showed ST elevation in V1-V3 in the setting of raised cardiac enzymes, and 2d-echo demonstrating regional wall motion abnormality. He was diagnosed to have acute anteroseptal MI and thrombolysed with streptokinase. Subsequently, his coronary angiogram showed a non-occluded LAD. CT Angio with IVUS done at a staged interval revealed minimal luminal irregularities suggestive of MINOCA. 8 months later the patient presented with headeache, fever, and left focal seizure accompanied by signs of increased intracranial pressure. MRI brain with contrast-MR venogram showed complete thrombosis of superior sagittal sinus. Due to the previous history of MI, and present CVT the patient was subjected to detailed thrombophilic evaluation which was normal except the levels of vitamin B12 (126.9 pg/mL) was low his homocysteine level was abnormally elevated to a level of 38.23 μM/L. The patient was treated with heparin, anti-oedema measures and anti-epileptics followed by oral anticoagulant plus folate, vitamin B6, and vitamin B12. Young patients presenting with arterial or venous thrombosis without any risk factors for atherosclerosis and venous thrombosis which is recurrent, unexplained, or at unusual sites, need screening for thrombophilic states and hyperhomocysteinemia should be ruled out as it can lead to both arterial and venous disease.