1420 - Bullous Pemphigoid as an Independent Risk Factor for Ischemic Stroke: A Case Report

Case Diagnosis: Bullous pemphigoid and multiple ischemic strokes

Case Description: A 69-year-old female with a medical history of hypertension, hyperlipidemia, heart failure, and prior ischemic strokes presented with new-onset left arm weakness. She had a documented left anterior cerebral artery (ACA) watershed stroke in February 2025 with residual right foot drop and a right ACA stroke in July 2025 resulting in left leg weakness. On current evaluation, imaging revealed a new right ACA occlusion and multifocal intracranial atherosclerotic disease. During hospitalization, the patient was also noted to have tense bullous lesions on her trunk and extremities. Dermatology was consulted, and following clinical evaluation and review of laboratory data, a diagnosis of bullous pemphigoid was confirmed.

Discussions:

Bullous pemphigoid (BP), an autoimmune blistering disorder, has been increasingly associated with an elevated risk of thrombotic events, including ischemic stroke. While the exact pathophysiological mechanisms remain unclear, chronic systemic inflammation and potential prothrombotic states are implicated. This case demonstrates recurrent ischemic strokes in a patient with BP and multiple vascular risk factors, highlighting BP as a possible independent contributor to cerebrovascular events.

Conclusions: This case underscores the possible role of bullous pemphigoid as an independent risk factor for recurrent ischemic strokes, even in the presence of traditional vascular comorbidities. The temporal clustering of cerebral ischemic events around the onset of BP raises concern for an underlying proinflammatory or prothrombotic state driven by the autoimmune process. Growing epidemiologic evidence supports this association, suggesting that patients with BP may require closer vascular risk assessment and monitoring. Clinicians should maintain a high index of suspicion for cerebrovascular events in BP patients, particularly those with concurrent vascular risk factors.