Acute Ischemic Stroke in a Lupus Anticoagulant–Positive Woman With COVID-19

CLINICAL IMAGES

A 34-year-old woman was admitted with onset of loss of speech and right hemiparesis. She had experienced a fever and a slight dry cough for 2 to 3 days before the stroke. The physical examination showed motor aphasia, right facial asymmetry, right hemiparesis, and extensor response of right plantar reflex. The magnetic resonance imaging scan showed diffusion retraction in the left area of the middle cerebral artery (Fig. 1). Chest computed tomography scan was performed to investigate the cause of her fever and to determine whether she had COVID-19 (coronavirus disease 2019). The chest computed tomography scan showed bilateral subpleurally located ground-glass opacities (Fig. 2), and patient's COVID polymerase chain reaction test result was positive. Treatment was started with acetyl salicylic acid, enoxaparin, favipiravir, hydroxychloroquine, and azithromycin. Antinuclear antibody and lupus anticoagulant (LAC), using blood drawn before the initiation of heparin therapy, were positive. Anti-Sm, anti-dsDNA antibody, anticardiolipin, and β2-glycoprotein were all negative. With maintenance therapy, she recovered her ability to speak and most of her strength on her right side, and her fever and cough have resolved. Several case reports have been published on COVID-19 patients with LAC and antiphospholipid antibodies, but it is unclear whether the LAC and antiphospholipid antibodies were directly related to the COVID-19. Beyrouti et al.¹ reported 5 cases of ischemic stroke in COVID-19 patients who were positive for LAC. Harzallah et al.² reported that 25 patients were positive for LAC in a French cohort of 56 patients with COVID-19. Bowles et al.³ reported that LAC assays were detected in 31 patients (91%) positive for LAC. Some studies have reported LAC has also been reported to be associated with viral infections.⁴ The assays that are used to detect LAC are also sensitive to the presence of CRP, which may be elevated in patients with pulmonary or systemic inflammatory states, and this is the limiting factor of this test in the acute inflammatory state.⁵ Our patient was a young woman who was diagnosed with an acute stroke and was subsequently diagnosed with COVID-19 and found to be LAC positive. As a result, in this COVID-19 patient, we hypothesize that LAC may have contributed to the thromboembolic event in a synergistic manner with the increased risk of thrombosis present in the course of this infection. COVID-19 patients with LAC have a significantly increased risk of thrombotic events, highlighting the importance of early detection to enable better treatment.

FIGURE 1.

Cranial diffusion magnetic resonance imaging scan showing diffusion retraction in the left middle cerebral artery M2 area.

FIGURE 2.

Chest computed tomography scan showing bilateral subpleurally located multiple ground-glass opacities.