Objective:

We present an interesting case of recurrent ischemic strokes in a patient with Immune Thrombocytopenia despite antiplatelet/anticoagulation stroke prophylaxis.

Background:

Primary Immune thrombocytopenia (ITP) is an autoimmune acquired thrombocytopenia caused by autoantibodies against platelet antigens leading to platelet destruction and platelet underproduction.  Patients with ITP usually have a higher risk of bleeding compared to general population, however thrombocytopenia in ITP is not necessarily protective against thrombosis. Prior research demonstrated increased risk of venous and arterial thromboses such as DVT, PE, myocardial infarction and stroke in patients with ITP. The pathogenesis of hypercoagulability in ITP is not well understood. It may relate to inflammation, antiphospholipid antibodies in some patients, or the effects of certain treatments such as glucocorticoids and thrombopoietin-receptor agonists (TPO-RAs).

Design/Methods:

Single Case Report 

Results:

65-year-old male patient with history of COPD, unprovoked DVT on Rivaroxaban who presented initially with worsening headaches and cognitive dysfunction. CT head showed bilateral subacute frontal lobe infarcts that looked embolic in nature. Initial bloodwork showed thrombocytopenia (54,000), hypercoagulable workup including anticardiolipin antibody, antiphospholipid antibody, beta 2 glycoprotein antibody, factor V Leiden, Prothrombin gene mutation was negative. Bone marrow biopsy showed immature megakaryocytes without morphological pathology. TTE/TEE without intracardiac or intrapulmonary shunts and telemetry without evidence of arrhythmias. Patient was transitioned from Rivaroxaban to Warfarin with INR goal of 2.0-3.0, glucocorticoids and subsequent Rituximab infusion were initiated with improvement of platelets count on follow-up. 8 months following his discharge, patient presented with new onset Rt pontine infarct, INR at that time was 2.34, repeat stroke workup was unrevealing. 

Conclusions: