A Case of Catastrophic Antiphospholipid Antibody syndrome

Abstract

A 34- year-old nonsmoker female patient got admitted to our hospital with the complaints of black discolouration of the toes of left foot for 7 days. The black discolouration was associated with pain and it was progressive. She also complained of swelling of both lower limbs for last 5 days.

On query, she admits of decreased urinary output. She got history of recurrent first trimester abortion but her menstrual cycles were regular.

On examination , she was well-oriented, afebrile, pale, had periorbital swelling and  bilateral pitting oedema and rash on left thigh that does not blanch on pressure. Her blood pressure was 140/80mmHg, respiratory rate 20breath/min. Bed side urine test was not done. Her chest examination, abdomen and nervous system were unremarkable. Arterial pulses distal to femoral artery were absent in left lower limb.

The patient came with features of limb ischemia, acute kidney injury within a short period of time. Our provisional diagnosis was systemic vasculitis and differentials were antiphospholipid antibody syndrome and sepsis with disseminated intravascular coagulation (DIC). We sent the labs targeting the possible diagnosis.

Complete blood count shows: Haemoglobin- 8.5 gm/dl, ESR- 122 mm/in 1st hour, Total count of WBC- 12,400/cumm,RBC- 3.50 mIillin/uL,Platelet- 3,09000/cumm,Differential count- Neutrophil – 84% ,lymphocyte- 09%,Monocyte- 06%,Eosiniphil-01%,Basophil- 0%. Haematocrit- 26%, MCV-74 fl,MCH-24.4 pg,MCHC-32.8 gm/dl, Total Cir. Eosinophil count-124/cumm.

Renal panel showed- S. creatitine -321 micro mol/L, Urine R/E  Pus cell- 3-5 /HPF,RBC – Pleny,Epithelial cell- 15-20 / HPF. S. Electrolytes- Sodium-121.2 mmol/L,,potassium- 3.10 mmol/L, Chloride- 86.3 mmol/L. 24hrs Urinary total protien- 1.26g/24hrs,24hrs urinary volume- 700ml.

Ultrasonogram of abdomen revealed - Mild increased cortical echogenicity of both kidneys, Mild free fluid in cul-de- sac. Echo-  no regional wall motion abnormality present, EF-65%

CRP- 278 mg/L, Random blood sugar- 5.6 mmol/LS. bilirubin- 1,10 mg/L, Alkaline phosphatase- 187 U/L,PT: 14.4sec,  INR-1.11,APTT- 37.4 sec, Albumin – 25gm/L, Uric Acid- 8.7 mg/dL.

Other Immunological tests results are-Serum C3- 18.0 mg/dl,Serum C4- 7.0mg/dl,RA/RF- 9.7IU/mL

ANA- 220.0[positive], Anti  CCP- 6 U/mL (neg),VDRL-  Non reactive

Anti Cardiopin IgG- 27.79 GPL-U/ml (positive)

Anti Cardiolipin IgM- 8.63 MPL-U/Ml ( positive)

X-ray left leg B/V– Normal findings

DUPLEX colour Doppler study of left lower limb vessels:  Mild diminished blood flow of Arterial dorsalis pedis artery and no DVT

Bangladesh J Medicine 2026; Vol. 37, No. 2(1): pp. 228