Case
A 46-year-old female, who is a known case of IBD-UC, presented with
intermittent chest pain for more than 24 hours. Her history was
suggestive of a recent relapse of IBD-UC, for which she was on
mesalamine and steroids. Electrocardiogram (EKG) showed ST elevations in
inferior leads ( II, III, aVF). She was loaded with dual antiplatelet
and high-dose statins. 2D Echocardiogram revealed regional wall motion
abnormality with an ejection fraction of 35%. Coronary angiography
revealed thrombus in all three main arteries with >90%
occlusion in LAD (left anterior descending artery), LCX (left circumflex
artery), and near-complete occlusion of RCA (right coronary artery), and
ramus. (Figure 1). Considering her delayed presentation, prothrombotic
state, and keeping in mind the immediate complications of stent
placement, only thrombosuction was done, achieving grade 3 TIMI flow.
Intravenous antiplatelet (abciximab) infusion was administered for 48
hours. Laboratory investigations revealed anemia (Hb-11gmdl),
leucocytosis (11,000 per microliter) with neutrophilic predominance, and
thrombocytosis (9,00,000 per microliter ). Her troponin was 6.5(
reference range 0-0.02). RA factor and hs-CRP were elevated, suggesting
an active inflammatory state. The Thrombophilia profile was negative (
protein C, protein S antithrombin III, antiphospholipid antibodies). She
was negative for ANA, vasculitis profile, AMA, Anti smooth muscle, and
anti-LKM antibodies. Complement levels were normal. Sigmoid ulcers with
no active bleeding were seen on colonoscopy. Bone marrow biopsy reported
hypercellular marrow with no evidence of any myeloproliferative
neoplasm. During her hospital stay, she had an episode of atrial
fibrillation, for which she was put on amiodarone and NOACs (apixaban)
as there was no evidence of bleeding from sigmoid ulcers in colonoscopy.
She was discharged on single antiplatelet and NOACs and was advised for
further follow-up in OPD (outpatient department). She did not report any
chest pain for the next two weeks. However, a repeat coronary
angiography six weeks later showed surprising results with a
near-complete resolution of thrombus from RCA and complete resolution
from LCX and LAD(Figure 2). A repeat 2D Echocardiogram revealed a
significant increase in ejection fraction from 35% to 45-50%.