Ischaemic stroke in a patient with myasthaenic crisis and antiphospholipid antibody syndrome

Abstract

While autoimmune diseases have been frequently found to coexist in the same patients, the co-occurrence of myasthaeniagravis and antiphospholipid antibody syndrome (APAS) has only been reported in eight cases. We present a case of a 46-year-old Filipina who developed ischaemic stroke while admitted at the neurocritical unit for myasthaenic crisis. She was successfully thrombolysed with intravenous recombinant tissue plasminogen activator (rTPA), given a regimen of intravenous Ig and a dose of cyclophosphamide prior to discharge. Extensive workup revealed APAS to be the aetiology of her stroke. Twenty-one months into her follow-up, she is doing well with a modified Rankin Score of 0. Our case suggests that rTPA followed by immunomodulators may be given safely in myasthaenic crisis patients who develop ischaemic stroke. We emphasise the importance of doing a comprehensive neurological evaluation in agitated patients in the critical care unit.

Keywords: immunology; neurology; neuromuscular disease; stroke.

Figure 1

Intracranial imaging. (A–C) Plain cranial CT scan done 70 min after ictus. (D–F) Fluid-attenuated inversion recovery (FLAIR) sequence of a cranial MRI done 14 days after ictus showing an infarct (white arrow) in the parietal subcortical region corresponding to the left middle cerebral artery territory. (G) Cranial magnetic resonance angiography showing normal cerebral vasculature.