Acute Ischemic Stroke in a Lupus Anticoagulant–Positive Woman With COVID-19

CLINICAL IMAGES A 34-year-old woman was admitted with onset of loss of speech and right hemiparesis. She had experienced a fever and a slight dry cough for 2 to 3 days before the stroke. The physical examination showed motor aphasia, right facial asymmetry, right hemiparesis, and extensor response of right plantar reflex. The magnetic resonance imaging scan showed diffusion retraction in the left area of the middle cerebral artery (Fig. 1). Chest computed tomography scan was performed to investigate the cause of her fever and to determine whether she had COVID-19 (coronavirus disease 2019). The chest computed tomography scan showed bilateral subpleurally located ground-glass opacities (Fig. 2), and patient's COVID polymerase chain reaction test result was positive. Treatment was started with acetyl salicylic acid, enoxaparin, favipiravir, hydroxychloroquine, and azithromycin. Antinuclear antibody and lupus anticoagulant (LAC), using blood drawn before the initiation of heparin therapy, were positive. Anti-Sm, anti-dsDNA antibody, anticardiolipin, and β2-glycoprotein were all negative. With maintenance therapy, she recovered her ability to speak and most of her strength on her right side, and her fever and cough have resolved. Several case reports have been published on COVID-19 patients with LAC and antiphospholipid antibodies, but it is unclear whether the LAC and antiphospholipid antibodies were directly related to the COVID-19. Beyrouti et al. reported 5 cases of ischemic stroke in COVID-19 patients who were positive for LAC. Harzallah et al. reported that 25 patients were positive for LAC in a French cohort of 56 patients with COVID-19. Bowles et al. reported that LAC assayswere detected in 31 patients (91%) positive for LAC. Some studies have reported LAC has also been reported to be associated with viral infections. The assays that are used to detect LAC are also sensitive to the