(221) Triad of Crisis: Stroke, Myocardial Infarction, and Myeloproliferative Disorder in One Admission

Introduction: Myeloproliferative disorders (MPDs) create a prothrombotic milieu as there is an elevated number of reactive reticulated platelets with more aggregative features. The simultaneous presence of stroke and myocardial infarction (MI) in MPDs is not prevalent and we aim to share this case and hopefully guide future encounters.

Description: A 61-year-old African American female was found unresponsive at home, seen by emergency medical services, hemodynamically stable, EKG read ST elevation. Presented as a STEMI notification, however, was noted to have left-sided facial droop, aphasia, and altered mental status. No STEMI on EKG. Vitals: BP 116/71, HR 82, RR: 23, T: 37.5C. Labs: WBC 18, Hgb 13, Plt: 1816000, Trop 178 (repeat: 4916). Urine toxicology negative. Chest X-ray: right lower lobe infiltrate. Computed tomography (CT) brain: No acute infarct, CT Angiography head/neck: No large vessel occlusion. Neurology evaluated, MRI brain: acute brainstem infarcts and was started on ASA and atorvastatin. Anticoagulation approval was issued and then admitted to the intensive care unit. Hematology assessed for thrombocytosis, positive for JAK2 mutation, c.1849G>T (p.V617F). Blood smear: increased number of platelets and megakaryocytes. Started hydroxyurea 1000mg BID and reduced to 500mg TID as platelet count trended down. As per cardiology, started on clopidogrel, and heparin drip (later discontinued). Transthoracic echocardiogram noted biventricular diffuse hypokinesis with regional variability, ejection fraction 30-40%, bubble study positive but lower extremity duplex negative for deep venous thrombosis. Guideline-directed medical therapy started. The stress test was equivocal, pending left heart catheterization. Seen by Infectious Disease for aspiration pneumonia, not on supplemental oxygen, blood (& urine) cultures were negative, covered with ampicillin-sulbactam and doxycycline. Unfortunately, the patient expired during this admission of unknown cause.

Discussion: MPDs come with a procoagulant state but also with high bleeding risk from acquired von Willebrand syndrome. This patient was hemodynamically stable, not requiring oxygenation or vasopressors but suddenly became pulseless. This case highlights the severe acuity of this complex presentation and we hope guides future care for these patients.