Lupus anticoagulant and ischemic myocardial microangiopathy in rheumatoid arthritis

Background: A 49-year-old man presented at a hospital with an arthritic flare-up and stress dyspnea with a cough. He had a 5-year history of symmetrical polyarthritis, for which he was prescribed 5-15 mg prednisolone daily. He was subsequently diagnosed with rheumatoid arthritis and prescribed 20 mg methotrexate weekly, 3 mg/kg ciclosporin daily and 5 mg prednisolone daily. Infliximab therapy was initiated after 3 months because of persistent joint pain and inflammation. Six months later, however, the patient was readmitted to hospital with a new arthritic flare-up, acute retrosternal chest pain and stress dyspnea. Investigations: Laboratory analyses, electrocardiography, chest radiography, high-resolution CT, echocardiography, technetium-99m-labeled (^99mTc)-methoxyisobutyl-isonitrile stress myocardial scintigraphy and coronary angiography. Diagnosis: Lup us anticoagulant and ischemic myocardial microangiopathy. Management: Drug therapy with prednisolone, methotrexate, anakinra, aspirin and clopidogrel.