A 17-year-old female patient with a history of occasional smoking and use of monthly injectable combined contraceptives.
No morbid or surgical history, noligesta.
She presented with urgency for 12 h of weakness of the right hemibody, difficulty to emit language and frontal headache.
She was hemodynamically stable and afflicted.
Physical examination revealed mild right brachiocrural hemiparesis and aphasia of expression, without meningeal signs and both plantar flexor reflexes.
No other changes in physical examination.
Brain computed tomography (without contrast) showed no abnormalities.
Brain MRI showed multiple infarctions in the territory of the left middle cerebral artery, suggesting embolic origin.
Laboratory tests were performed, highlighting platelets 128,000/mm3 and TTPK 48.
The patient was hospitalized.
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Transesophageal echocardiography was performed looking for cardiac embolic source, which revealed a sessile mitral vegetation of 11 per 9 mm. Three peripheral blood cultures were requested and empirical therapy with penicillin, cloxacillin was initiated.
However, the patient was inflammatory and had no change in parameters.
The patient was admitted with early regression of aphasia and hemiparesis, recovering within a few days normal mobility of the 4 limbs, without alterations or other neurological symptoms or signs.
On the sixth day of hospitalization, the patient presented a self-limited episode of fever.
During hospitalization, no other manifestations were investigated on physical examination.
Peripheral blood cultures were negative; they were kept in study for up to 21 days to rule out growth of fast bacilli, without positive results.
Brucella and Bartonella henselae serology were negative.
Due to suspicion of non-infectious endocarditis, a repletion study was performed, which showed: positive antinuclear antibodies (ANA) at 1:320 dilution with a mottled pattern; negative anti-DNA antibodies; negative ENA profile and normocompaction
We also decided to perform a FAS study, all of which were positive.
Anticoagulant treatment with heparin was initiated, followed by oral anticoagulation with acenocoumarol.
In addition, 28 days of empirical antibiotics were completed.
The patient was admitted favorably with no new thromboembolic manifestations.
She was discharged with permanent oral anticoagulation and maintained in rheumatology controls.
Six months later, the antiphospholipid antibodies in blood became positive again.
