A 57-year-old woman presents for follow-up several months after a series of thrombotic episodes. Four days after she underwent ankle fusion to relieve pain and edema associated with a leg fracture that had occurred 40 years earlier, she sustained a massive myocardial infarction (MI). She required support with a left ventricular assist device and will eventually need cardiac transplantation. Later in the perioperative period, she sustained 2 strokes and was found to have bilateral below-the-knee deep venous thromboses (DVTs).
Six months after the MI, while she was receiving prophylactic anticoagulation, a proximal DVT developed and a splenic infarct occurred, necessitating a splenectomy. Since then, she has been receiving low molecular weight heparin (LMWH).
The patient has never smoked or abused alcohol or drugs. Her father died of an MI in his 60s. She has no other family history of cardiovascular or hematological disease. She has 3 healthy children and had 1 spontaneous abortion. She is a disabled bookkeeper.
Vital signs are normal. Results of cardiac and pulmonary examinations are normal, and no lymphadenopathy is noted. On her abdomen, well-healed surgical scars and ecchymotic areas secondary to LMWH injections are evident. Her calves are large in diameter and her ankles show hemosiderin deposition, but there is no pitting edema. She has a normal gait but a mild expressive aphasia.
A hemogram and biochemistry profile are normal. Her international normalized ratio (INR) is 2.6. Partial thromboplastin time is 67 seconds (normal, 25 to 35 seconds).
Which of the following is the most likely diagnosis in this patient?
A. Factor V Leiden mutation.
B. Prothrombin gene mutation.
C. Lupus anticoagulant and anticardiolipin antibody syndrome.
D. Antithrombin III deficiency.
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