Q: 34 year old female with no significant past medical history is admitted to ICU with ischemic stroke, confirmed by CT and follow up MRI in ED. Enthusiastic medical student did proper physical exam and reports the presence of  'livedo reticularis'. What is the most probable diagnosis?

Answer: Anti-phospholipid (aPL) syndrome

It is called “Sneddon's syndrome”. One of the clinical systemic finding (present in about 20% of the patients)  in patients with aPL and an ischemic cerebrovascular disease is livedo reticularis.
Interestingly, after deep vein thrombosis (DVT) and thrombocytopenia, this is the most common clinical finding in patients with aPL. Other clinical findings may be superficial thrombophlebitis, pulmonary embolism and fetal loss. To note, stroke is found to be more common than transient ischemic attack (TIA) in patients with aPL.


 References:

1. Levine SR, Langer SL, Albers JW, Welch KM. Sneddon's syndrome: an antiphospholipid antibody syndrome? Neurology 1988; 38:798.

2. Francès C, Papo T, Wechsler B, et al. Sneddon syndrome with or without antiphospholipid antibodies. A comparative study in 46 patients. Medicine (Baltimore) 1999; 78:209.

3. Cervera R, Piette JC, Font J, et al. Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients. Arthritis Rheum 2002; 46:1019.