A 44 y.o. woman comes in with an ischemic L arm
do you see a possible explanation?
yes, she does have a splenic infarct
Our patient had a clot in the aorta with emboli to the spleen and L arm.
the brachial clot
She underwent an evaluation for a hypercoagulable state or arrhythmia. Her thrombophilia workup included antiphopholipid antibodies, antithrombin, and factor 5 Leiden. She had a positive ANA but no evidence of a hypercoagulable state. Her evaluation for arrhythmia or clot in the heart was negative. The most likely cause of the patient’s sudden arterial thrombosis was felt to be poorly controlled hypertension with risk factors being smoking and methamphetamine use.
HOW DOES METHAMPHETAMINE CONTRIBUTE TO A HYPERCOAGULABLE STATE?
Methamphetamine enhances monoamine (dopamine and NE) levels in the synaptic cleft. It is the most widely used illicit drug in the world after cannabis. The extra methyl group on methamphetamine makes it highly lipophilic allowing it to penetrate the blood-brain barrier. There it interferes with dopamine and norepinephrine transporters causing an increase in dopamine and NE signaling resulting in euphoria. The downsides of meth include: vasooconstriction( leading to MIs), and endothelial damage with accelerated atherosclerosis. Chronic users are also susceptible to pulmonary hypertension and cardiomyopathy.
meth mouth
Another downside to meth use is “meth mouth”. Meth mouth is caused by several factors. There is a decrease in saliva production which causes an increase in bacteria. While high meth users crave sweets and often grind their teeth. Meth is made up of acidic compounds like battery acid and household cleaning agents and fertilizers which may add to the problem.
Our patient initially underwent a removal of the clot in the brachial artery and forearm fasciotomy.Her pain improved and she was discharged. Her pain resolved.
forearm fasciotomy
The clot could only be partially removed since a clot still remained in the aorta. She returned several days later with another clot at the brachial artery on the L. This was removed and she was advised to discontinue meth use.
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Won S, Hong R, Shohet R,et al. Methamphetamine-associated cardiomyopathy. Can Cardiol 2013;36:737-742.
Alla V, Thota R, Mathias S, et al. Mobile thoracic aortic thrombus in a methamphetamine user after cardiac arrest. Tex Heart Inst J. 2011;38(4):445-447.
Senst B, Tadi P, Basit H, Jan A. Hypercoabulability. StatPearls Treasure Island (FL):StatPearls Publishing Jan 2023.