# Pulmonary Embolism and Myocardial Infarction With Non-obstructive Coronary Arteries in Immune Thrombocytopenia: Unmasking Underlying Antiphospholipid Syndrome

## TL;DR

A 35-year-old man with immune thrombocytopenia developed a rare combination of pulmonary embolism and heart attack due to an undiagnosed antiphospholipid syndrome.

## Contribution

Highlights a rare case linking immune thrombocytopenia treatment with antiphospholipid syndrome and paradoxical thrombosis.

## Key findings

- Patient presented with PE and MINOCA while on avatrombopag for ITP.
- Diagnosis of antiphospholipid syndrome and PFO explained the paradoxical thrombosis.
- Treatment was adjusted to warfarin and an alternative ITP medication.

## Abstract

This case report presents the clinical scenario of a 35-year-old male patient who experienced chest pain due to a combination of pulmonary embolism (PE) and myocardial infarction with non-obstructive coronary arteries (MINOCA), concurrently while undergoing treatment with avatrombopag for immune thrombocytopenia (ITP). His investigations included a CT pulmonary angiogram that confirmed a PE, a coronary angiography which was normal, a cardiac MRI which showed evidence of subendocardial infarct, and a CT coronary angiogram, which was normal. His unique presentation with these findings prompted further investigations, which revealed an undiagnosed antiphospholipid syndrome (APS) alongside a patent foramen ovale (PFO). Hence, the paradoxical thrombotic incidents were precipitated by this unique diagnosis. After establishing the diagnosis, our patient was commenced on warfarin, and his treatment protocol for ITP was changed to a different drug. He remains under haematology follow-up.