A 30 years old thin male with a clear medical background presented to the emergency department at Medani Heart Centre (MHC) with central crushing chest pain with maximum intensity radiated to the left shoulder and jaw aggravated by movement and improved by rest not associated with cough or shortness of breath and not improved by ingestion of food or Antacids. The patient denied fever, change in appetite, diarrhea, vomiting, change in urine, headache or any other form of neurological symptoms.
However there was no past history of a similar condition or cardiac problems. The patient mentioned that he is a heavy smoker and has had unprotected sexual intercourse many times. The patient denied drinking alcohol.
On examination the patient looked ill, thin and not pale or jaundiced, pulse 110 regular good volume, Bp100/60 bilaterally, normal pericardium findings, clear chest and soft abdomen. ECG showed Significant ST segment elevation from v1 to v6 and mild elevation in leads 2, 3 and avF confirmed later by positive serum troponin as Late Extensive ST segment elevation Myocardial Infarction crushed by aspirin 300mg, clopidogrel 300 mg, bisoprolol 2,5 mg, Enoxaparin inj. weight 1 kg 12 hourly and the patient was scheduled for urgent Coronary Angiography but during preparation the ICT for HIV tested positively necessitating confirmation with ELISA which showed a high viral load of 22.4 AU/ml (normal up to 1 AU/ml). Other tests revealed normal fasting lipid profile, complete blood count and normal renal function tests with electrolytes.
Echocardiography showed anterior, septal, apical and anterolateral wall hypokinesia with two apical thrombus measures 11 x 10 cm, 10 x 12 cm subsequently with moderately impaired left ventricular systolic function (Ejection Fraction=34) favoring the decision of adding furosemide 40 mg tabs once daily and spironolactone tabs 25 mg once daily. See Figure 1
The patient was followed up closely symptomatically with serial ECGs on the subsequent days showing significant improvement until day 4 of Admission in the evening follow up when he was found to have slurred speech and he mentioned that he was unable to move his right side, without mouth deviation, headache or blurring of vision. On examination he was afebrile, conscious, oriented in time, place and person. There was bulbar cranial nerves affection (without fascial palsy), right side hypotonia, power grade 3 and hyporeflexia. The patient was sent for urgent brain CT scan which showed left parietal area infarction. See Figure 2
The patient was followed up for the following 5 days showing complete recovery and returned speech fluency with normal tone, power grade 5 and normal reflexes. He was discharged after being counseled perfectly on full anti-ischemic and diuretics with enoxaparin shifted to rivaroxaban 15 mg 12 hourly sent to HIV program for proper management to be seen after two weeks in the Cardiology Referral Clinic.