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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 1  |  Page : 35-37

Stroke in a young adult receiving intravenous immunoglobulin therapy for immune thrombocytopenic purpura


College of Medicine, King Khalid University, Abha, Saudi Arabia

Date of Web Publication25-Apr-2016

Correspondence Address:
Javed Iqbal Wani
Department of Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5127.181112

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  Abstract 

Intravenous immunoglobulin (IVIG) is increasingly being used in wide variety of auto-immune and inflammatory disorders. FDA has approved the use of IVIG in primary and secondary immune-deficiencies like Chronic Lymphoid leukemia, HIV infection, prevention of GVHD in bone marrow transplantation, ITP, Polymyositis and Kawasaki's disease, pemphigus vulgaris and Guillain barre syndrome and many other disorders.(1). Although they are generally considered safe however, thrombotic complications are being recognized more often in recent years including arterial and venous thrombosis after being used in wide range and extended spectrum of disorders, (2). We report a case of thrombotic stroke in a young adult patient who received IVIG for acute ITP and had no underlying risk factors for development of stroke.

Keywords: Intravenous immunoglobulin, stroke, thrombosis


How to cite this article:
Wani JI. Stroke in a young adult receiving intravenous immunoglobulin therapy for immune thrombocytopenic purpura. J Appl Hematol 2016;7:35-7

How to cite this URL:
Wani JI. Stroke in a young adult receiving intravenous immunoglobulin therapy for immune thrombocytopenic purpura. J Appl Hematol [serial online] 2016 [cited 2022 Aug 19];7:35-7. Available from: https://www.jahjournal.org/text.asp?2016/7/1/35/181112


  Introduction Top


Intravenous immunoglobulin (IVIG) is increasingly being used in wide variety of auto-immune and inflammatory disorders. Food and Drug Administration has approved the use of IVIG in primary and secondary immune deficiencies such as chronic lymphoid leukemia, HIV infection, prevention of graft-versus-host disease in bone marrow transplantation, idiopathic thrombocytopenic purpura (ITP), polymyositis and Kawasaki's disease, pemphigus vulgaris and Guillain–Barre syndrome and many other disorders.[1] Although they are generally considered safe, thrombotic complications are being recognized more often in recent years including arterial and venous thrombosis after being used in a wide range and extended spectrum of disorders.[2] We report a case of thrombotic stroke in a young adult patient who received IVIG for acute ITP and had no underlying risk factors for the development of stroke.


  Case Report Top


A 30-year-old female, known to have ITP who was having occasional symptoms of excessive menstrual bleeding with a platelet count ranging from 30,000 to 40,000/cumm and was not on any treatment, presented with a history of epistaxis which was preceded by a flue like illness. Her clinical examination was essentially normal except few petechiae over the trunk. Her platelet count was 4000/cumm. She was given IVIG 1 g/kg body weight over a period of 4 h, in addition to prednisolone 1 mg/kg. On next morning, her platelet count improved to 27,000/cumm, and she had no further bleeding. She was given the second dose of IVIG, and during the infusion, she complained of a mild headache and myalgias which resolved with oral paracetamol. The patient went to sleep. However she could not get up in the morning and was not able to move her right side of the body. Clinical examination revealed that patient was aphasic and had dense hemiplegia on the right side with grade zero power in all groups of muscles on the right side of the body. An immediate computed tomography (CT) scan of the brain was normal with no evidence of hemorrhage or infarction. Platelet count was 67,000. She was managed in Intensive Care Unit with supportive care, steroids and aspirin. She was investigated for any underlying cause of secondary causes of stroke in a young patient. A follow-up CT scan of the brain after 48 h revealed a large infarct in the left hemisphere extending to temporal and frontal areas [Figure 1]. She improved gradually over a period of 4–6 weeks and re-gained grade 4 power in all her muscles on the right side but was persisting with mild dysarthria.
Figure 1: Computed tomography scan showing infarction of left frontal and temporal lobe

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Subsequent investigations revealed erythrocyte sedimentation rate 15 mm, fasting glucose 89 mg/dl, liver function tests and lipid profile was normal. Antinuclear antibody and anti-ds DNA were negative, anti-cardiolipin antibodies and lupus anti-coagulant were negative. Her electrocardiogram, echocardiography and carotid Doppler were normal. Serum Vitamin B12, folic acid, and homocysteine levels were also normal.


  Discussion Top


Although the use of IVIG, in general, is considered safe, adverse side effects have been reported with varying degree of frequency. Mild and transient adverse side effects include a headache, flushing, chills, myalgias, wheezing, tachycardia, lower back pain, nausea, and hypotension are more common, occurring between 10% and 30% of cases.[3] Less common but serious side effects including anaphylactoid reactions, acute kidney injury and thrombotic events such as stroke, deep venous thrombosis, pulmonary embolism, and myocardial infarction are being increasingly reported in the literature.[4],[5],[6] The overall incidence of thromboembolic complications has been reported 3–5% in various studies and occurs, especially in adult patients having underlying risk factors including increasing age, previous thrombo-embolic diseases, chronic bedridden state, high dose of IVIG and fast rate of infusion.[7],[8],[9] The incidence of such complications being very low in children, especially those, being treated for acute ITP.[10] Our patient was a young adult without any underlying co-morbidities or any risk factor for the development of stroke in young individual, for which she was investigated. Marie et al.[7] have reported higher incidence (13%) of thrombotic complications in their series a 46 patient treated with IVIG but the high rate of complications have been correlated to the diversity of underlying medical conditions which had a higher risk for thrombosis. In many reports use of high dose IVIG, has been associated with in many cases leading to thrombotic complications including cerebral thrombosis, pulmonary embolism and acute myocardial infarction.[7],[8] These complications have been reported by many authors from Japan, especially treating children suffering from Kawasaki disease with high dose IVIG.[11],[12],[13] The high incidence of these complications in these cases could be related to the Kawasaki disease itself, involving the blood vessels and predisposing to thrombosis. The high doses also increase the viscosity of blood and precipitate the onset of thrombosis. The rate of infusion has also been incriminated to the onset of thrombosis.[14] In our patient, the rate of infusion was normal, but the dose of IVIG was possibly high, which is the only factor for the development of thrombosis in her. We conclude that although, the benefits of IVIG are well established, and even the drug is generally considered safe, but due to its increased usage for diverse conditions, many serious complications are being increasingly reported in the literature. Physicians need to be aware of such complications and take due precautions, keeping in mind the underlying medical co-morbidities while making a patient selection for this treatment. In addition, the patient needs to be explained for such possible serious complications to avoid any medical negligence cases against them.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Knezevic-Maramica I, Kruskall MS. Intravenous immune globulins: An update for clinicians. Transfusion 2003;43:1460-80.  Back to cited text no. 1
    
2.
Hamrock DJ. Adverse events associated with intravenous immunoglobulin therapy. Int Immunopharmacol 2006;6:535-42.  Back to cited text no. 2
    
3.
Katz U, Shoehfeld Y. Review: intravenous immunoglobulin therapy and thromboembolic complications. Lupus 2005;14:802-8. doi: 10.1191/0961203303lu2168rr.  Back to cited text no. 3
    
4.
Zaidan R, Al Moallem M, Wani BA, Shameena AR, Al Tahan AR, Daif AK, et al. Thrombosis complicating high dose intravenous immunoglobulin: Report of three cases and review of the literature. Eur J Neurol 2003;10:367-72.  Back to cited text no. 4
    
5.
Graumann A, Zawada ET Jr. Case report: Acute renal failure after administering intravenous immunoglobulin. Postgrad Med 2010;122:142-7.  Back to cited text no. 5
    
6.
Vucic S, Chong PS, Dawson KT, Cudkowicz M, Cros D. Thromboembolic complications of intravenous immunoglobulin treatment. Eur Neurol 2004;52:141-4.  Back to cited text no. 6
    
7.
Marie I, Maurey G, Hervé F, Hellot MF, Levesque H. Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature. Br J Dermatol 2006;155:714-21.  Back to cited text no. 7
    
8.
Rajabally YA, Kearney DA. Thromboembolic complications of intravenous immunoglobulin therapy in patients with neuropathy: A two-year study. J Neurol Sci 2011;308:124-7.  Back to cited text no. 8
    
9.
Orbach H, Katz U, Sherer Y, Shoenfeld Y. Intravenous immunoglobulin: Adverse effects and safe administration. Clin Rev Allergy Immunol 2005;29:173-84.  Back to cited text no. 9
    
10.
Benadiba J, Robitaille N, Lambert G, Itaj NK, Pastore Y. Intravenous immunoglobulin-associated thrombosis: Is it such a rare event? Report of a pediatric case and of the Quebec hemovigilance system. Transfusion 2015;55:571-5.  Back to cited text no. 10
    
11.
Baba R. Effect of immunoglobulin therapy on blood viscosity and potential concerns of thromboembolism, especially in patients with acute Kawasaki disease. Recent Pat Cardiovasc Drug Discov 2008;3:141-4.  Back to cited text no. 11
    
12.
Nonaka Z. High-dose intravenous immunoglobulin treatment. Nihon Rinsho 2008;66:327-31.  Back to cited text no. 12
    
13.
Wada Y, Kamei A, Fujii Y, Ishikawa K, Chida S. Cerebral infarction after high-dose intravenous immunoglobulin therapy for Kawasaki disease. J Pediatr 2006;148:399-400.  Back to cited text no. 13
    
14.
Eibl MM. Intravenous immunoglobulins in neurological disorders: Safety issues. Neurol Sci 2003;24 Suppl 4:S222-6.  Back to cited text no. 14
    


    Figures

  [Figure 1]


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