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%.