warfarin and Hemiplegia

Fungal endocarditis (FE) is a rare disease, in which antifungal treatment is necessary. When FE is complicated with prosthetic heart valve and/or atrial fibrillation, the coadministration of antifungal agents and warfarin is inevitable. We report a case of rheumatic heart disease with atrial fibrillation who developed FE following prosthetic heart valve replacement. The international normalized ratio (INR) increased significantly during the antifungal treatment with fluconazole. A discussion of the antifungal strategy in FE patients with prosthetic heart valves and/or atrial fibrillation and the interaction between antifungal agents and warfarin was performed.. A 54-year-old Chinese woman experienced intermittent fevers, aphemia, and weakness in her right extremities. Her temperature was 38.7°C, and there was atrial fibrillation with heart rate 110 times/min. Neurological examination revealed that she had drowsiness, Broca aphasia, right central facial paralysis, and hemiplegia (Medical Research Council scale, upper limb grade 0, lower limb grade II).. Multiple infarction on magnetic resonance imaging and the occlusion of left middle cerebral artery suggested the occurrence of cerebral embolism. The presence of Candida parapsilosis in the results of 4 blood cultures and the existence of valve vegetation in the reexamination of echocardiogram supported the diagnosis of FE.. The patient was given antifungal therapy with fluconazol. The INR increased dramatically on the 9th day of antifungal treatment, and subcutaneous bruising occurred at the intravenous infusion site. The antagonist of vitamin K1 was used and warfarin was reduced to a smaller dosage. The antifungal agent was replaced with caspofungin.. Her speech improved significantly, and the muscle strength of her paralyzed side reached the Medical Research Council scale of grade IV. She continued to receive caspofungin for antifungal treatment with relatively stable INR and waited for heart valve surgery.. The choice of antifungal agents is often a big challenge for FE patients, especially when they need warfarin for anticoagulation. It is better to administer a low dose of warfarin while carefully monitoring the INR or choose the antifungal drugs with little or no effect on warfarin.

Topics: Antifungal Agents; Atrial Fibrillation; Candida parapsilosis; Candidiasis; Caspofungin; Combined Modality Therapy; Diagnosis, Differential; Endocarditis, Non-Infective; Female; Fluconazole; Hemiplegia; Humans; Infarction, Middle Cerebral Artery; Middle Aged; Mitral Valve; Prosthesis-Related Infections; Warfarin

Topics: Adolescent; Angioplasty; Anticoagulants; Balloon Valvuloplasty; Diagnosis, Differential; Edema; Enoxaparin; Female; Hemiplegia; Humans; Leg; May-Thurner Syndrome; Stents; Thrombectomy; Tissue Plasminogen Activator; Ultrasonography; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

A 69-year-old man who had essential thrombocythemia, for which he was taking no medications, suddenly developed aphasia and right hemiplegia and was admitted to the hospital. He was thought to have had an embolic stroke and was initially treated with warfarin. Although the international normalized ratio was in the therapeutic range, he had 3 additional ischemic stroke episodes with the same symptoms after the index stroke. Magnetic resonance angiographic examinations revealed serial changes in middle cerebral artery stenosis. After administration of an antiplatelet agent and hydroxyurea, he had no additional strokes.

Topics: Aged; Anticoagulants; Aphasia; Brain Ischemia; Cerebral Angiography; Cilostazol; Diffusion Magnetic Resonance Imaging; Hemiplegia; Humans; Hydroxyurea; Infarction, Middle Cerebral Artery; International Normalized Ratio; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Male; Perceptual Disorders; Platelet Aggregation Inhibitors; Stroke; Tetrazoles; Thrombocythemia, Essential; Warfarin

Thrombotic thrombocytopenic purpura (TTP), a complex thrombotic microangiopathy, remains an evolving enigma. A 49-year-old African-American woman presented with acute left hemiplegia, an ischemic cerebrovascular accident involving the right middle cerebral artery. Sequential appearance of thrombocytopenia and evidence of microangiopathic haemolysis led to the diagnosis of acquired idiopathic autoimmune TTP. This was managed with plasma exchange (PEX) and steroids. Early haematologic relapse within a month was managed with the addition of rituximab attaining sustained remission. The patient presented 3 years later with acute confusion and expressive aphasia due to multiple infarcts involving the left parieto-occipital cortex. Transoesophageal echocardiography demonstrated a pedunculated 6 mm mitral valvular mass consistent with a papillary fibroelastoma. Anticoagulation was instituted and the patient was continued on therapeutic oral warfarin. A haematologic relapse of TTP eventually emerged and was managed with PEX, steroids and rituximab. This vignette demonstrates several dilemmas in the clinical presentation, diagnosis and management of TTP in current day practice. Rituximab has adjuvant benefits to PEX and is being investigated as potential first-line therapy. Monitoring ADAMTS13 activity and inhibitor titre, as in our case, prove to have prognostic significance. Cardiac fibroelastomas are rare benign cardiac tumours usually arising from valvular endocardium with thromboembolic potential. One of the proposed mechanisms of origin of these masses is organizing thrombi in the setting of endocardial injury and inflammation questioning a possible link to thrombotic microangiopathy. To the best of our knowledge, this is the first report of this unique coexistence.

Topics: ADAM Proteins; ADAMTS13 Protein; Antibodies, Monoclonal, Murine-Derived; Anticoagulants; Female; Fibroma; Heart Neoplasms; Hemiplegia; Humans; Middle Aged; Mitral Valve; Plasma Exchange; Purpura, Thrombotic Thrombocytopenic; Rituximab; Steroids; Warfarin

A 35-year-old healthy male with no history of any past medical illness developed severe headache, vomiting and drowsiness while at high altitude (4,572 m) in the eastern Himalayan ranges. He was evacuated to a tertiary-care hospital where he was diagnosed to have cerebral sinus venous thrombosis (CSVT) on magnetic resonance imaging, with deep vein thrombosis (DVT) of his right popliteo-femoral vein on color Doppler study. Investigation for thrombophilia revealed protein S (PS) deficiency in this patient. Family screening revealed low levels of PS in two elder brothers. One brother had a history of 'stroke in young' at the age of 20 years with the other being asymptomatic. This established the hereditary nature of PS deficiency. We are not aware of any previously published report on hereditary PS deficiency combined with CSVT and DVT occurring at high altitude. However, 1 case of protein C deficiency with CSVT has been reported previously.

Topics: Acclimatization; Adult; Altitude Sickness; Anticoagulants; Anticonvulsants; Cerebral Infarction; Family Health; Hemiplegia; Humans; Male; Military Personnel; Papilledema; Protein S Deficiency; Radiography; Recurrence; Sinus Thrombosis, Intracranial; Thrombophilia; Thrombophlebitis; Ultrasonography; Vomiting; Warfarin

Topics: Anticoagulants; Aortic Arch Syndromes; Cerebrovascular Disorders; Diabetes Complications; Diabetic Angiopathies; Female; Hemiplegia; Humans; Ischemia; Leg; Middle Aged; Postoperative Complications; Warfarin

Topics: Aged; Aged, 80 and over; Cervical Vertebrae; Combined Modality Therapy; Dexamethasone; Hematoma; Hemiplegia; Hemorrhage; Humans; Laminectomy; Male; Plasma; Spinal Cord; Spinal Cord Compression; Spinal Cord Diseases; Vitamin K; Warfarin

Cerebral dural sinus thrombosis is an unusual syndrome in which a patient presents with a severe headache that may be associated with diverse neurologic and physical findings. The case of a 31-year-old woman with headache, vomiting, generalized tonic-clonic seizure, and subsequent dense hemiplegia is presented. The patient was diagnosed as having a cerebral dural sinus thrombosis, but only after the diagnosis was missed initially. The syndrome may be difficult to detect because it can mimic several other entities. There are several known or suspected predisposing factors. The syndrome, diagnostic modalities, and therapeutic options are reviewed.

Topics: Adult; Cerebral Hemorrhage; Contraceptives, Oral; Diagnosis, Differential; Female; Headache; Hemiplegia; Heparin; Humans; Magnetic Resonance Imaging; Mannitol; Phenytoin; Seizures; Sinus Thrombosis, Intracranial; Tomography, X-Ray Computed; Warfarin

Topics: Adolescent; Female; Heart Aneurysm; Heart Ventricles; Hemiplegia; Humans; Magnetic Resonance Imaging; Middle Aged; Warfarin