Case Report: IVIG as a bridging strategy in high-risk antiphospholipid syndrome with infected cutaneous ulceration and thrombocytopenia.

BACKGROUND: Severe cutaneous ulceration in antiphospholipid syndrome (APS) with concurrent infection and thrombocytopenia presents a therapeutic dilemma: standard immunosuppression risks worsening infection, while anticoagulation risks hemorrhage. We present a high-risk case successfully managed using intravenous immunoglobulin (IVIG) as a bridging immunomodulatory strategy. CASE PRESENTATION: A 73-year-old man with triple-positive APS and immune thrombocytopenic purpura (ITP) developed rapidly progressive leg ulcers with clinical features consistent with pyoderma gangrenosum-like disease, complicated by active MRSA and Pseudomonas aeruginosa infection and severe thrombocytopenia (12 × 109/L). Standard therapies were contraindicated: corticosteroids risked worsening infection; anticoagulation risked hemorrhage. The patient received IVIG (0.4 g/kg per dose, every 3 weeks) as primary immunomodulation, concurrent targeted antimicrobial therapy, temporary anticoagulation interruption, and discontinuation of baseline mycophenolate mofetil. Following platelet recovery above 70 × 109/L, therapeutic anticoagulation was resumed with enoxaparin (80 mg subcutaneously twice daily) and aspirin (75 mg daily). Over five months, progressive re-epithelialization culminated in complete healing with platelet recovery. CONCLUSIONS: This case supports the feasibility of IVIG as a bridging immunomodulatory strategy in high-risk APS cutaneous disease where standard therapies are contraindicated by concurrent infection and thrombocytopenia. The sequential management approach successfully resolved a clinically challenging scenario. This case illustrates how risk-adapted immunomodulation may enable safe management of complex APS manifestations.