Recurrent Transient Ischemic Attacks in a Patient with POEMS Syndrome

A 47-year-old female with a prior history of POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome was admitted with transient ischemic attacks complicated by dysarthria and right-sided hemiparesis. A blood survey indicated thrombocytosis and hyperfibrinogenemia while imaging of intracranial vasculature showed occlusion of the bilateral middle cerebral arteries. POEMS syndrome, of which arterial thromboses have been mentioned as a manifestation, is rarely accompanied by transient ischemic attacks. The pathophysiologic mechanism is yet unclear and needs further investigation. 1. Introduction POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome is a paraneoplastic disorder due to an underlying clonal plasma cell neoplasm. Sclerotic bone lesions, elevated vascular endothelial growth factor, presence of Castleman disease, clonal plasma cells, and sensorimotor polyradiculoneuropathy are the major diagnostic criteria of the syndrome among which the latter two are sine qua non. At least one of the minor criteria, which include organomegaly, edema, endocrinopathy, skin changes, thrombocytosis/polycythemia, weight loss, hyperhidrosis, restrictive lung disease, diarrhea, and papilledema, is also required to establish the diagnosis [1]. Arterial thromboses have also been mentioned as a manifestation of POEMS syndrome. In contrast to the relatively frequent involvement of coronary and lower limb arteries, thromboses in cerebrovascular circulation have rarely been reported. 2. Case Report A 47-year-old female was admitted to our center with a 6-month history of transient ischemic attacks complicated with dysarthria and right-sided hemiparesis lasting 30 minutes. She experienced left-sided weakness on several occasions. She was describing as many as four to five attacks per day during the previous month. Her medical history was noteworthy for POEMS syndrome, which was diagnosed 2.5 months before her admission, hypertension, Hashimoto thyroiditis, and pulmonary embolism; and she was receiving calcium dobesilate, B complex vitamins, citalopram, trimetazidine, levothyroxine, warfarin, and acetyl salicylic acid daily and furosemide on alternate days. She had been diagnosed with diabetes mellitus and hyperlipidemia two years prior to admission to our center and had been treated with 30？mg gliclazide and 20？mg atorvastatin daily. A few months later she had discontinued her oral antidiabetic medication by her own will and was not restarted again because of good glycemic