intravenous immunoglobulin [ ivig ] is used for treatment of a variety of autoimmune , rheumatologic , and immunodeficiency [ both primary and secondary ] disorders and can be life - saving in several of these conditions . although it has good safety profile , it can be rarely associated with serious adverse events . thrombotic complications , both arterial and venous , are uncommon adverse events associated with ivig use . here , we report a case of acute st elevation anterior wall myocardial infarction [ mi ] associated with high dose [ 2 g / kg ] ivig administration in a previously healthy 69-year - old male patient of guillain barre syndrome [ gbs ] . the case is being reported to draw the attention of treating physicians to this uncommon , but serious adverse event associated with ivig administration . we have reviewed the literature on thrombotic complications associated with ivig in brief and measures to reduce them are discussed . a previously healthy , 69-year - old male manual laborer without addictions was admitted with complaints of progressive weakness of all the 4 limbs for 3 days . the weakness initially started in the lower limbs and then ascended rapidly to involve the upper limbs and neck muscles , forcing him to confine himself to bed . there was no history of preceding diarrheal illness , upper respiratory tract infection , or exposure to organophosphate insecticides . on admission to our hospital [ day-4 of illness ] , he was found to have symmetric areflexic quadriparesis with weakness of neck flexors [ power in lower limbs : grade 1/5 , upper limbs : grade 2/5 , neck flexors : grade 2/5 ] but extraocular and facial muscles , sensations , bowel and bladder were not affected . the patient was started on intravenous immunoglobulin [ norglobin ( 5 g/100 ml ) , containing maltose as excipient , marketed by claris lifesciences , ahmedabad ( india ) , dose : 0.4 g / kg / day  5 days ] , along with venous thrombosis prophylaxis [ enoxaparin ] from day-4 . he later had progressive paralysis with involvement of lower cranial nerves and respiratory muscles , needing endotracheal intubation , mechanical ventilation and nasogastric tube feeding in the intensive care unit from day-5 . the patient had autonomic dysfunction with episodes of hypertension and tachycardia on days- 4 and 5 , which resolved by day-6 . on day-8 , when the last dose of ivig was just about to be completed , patient had sudden unexplained episode of hypotension [ systolic blood pressure : 70 mm hg ] with profuse sweating and restlessness . an electrocardiogram [ figures 1 - 3 ] showed st segment elevation in leads v1 to v4 , suggesting acute anterior wall st elevation mi . patient 's blood pressure rose with inotropes [ norepinephrine and dopamine ] , and he received thrombolytic therapy [ streptokinase-15,00,000 units ] within 1 hour . echocardiography revealed hypokinesia of the interventricular septum and anterior wall of left ventricle with an ejection fraction of 40% . ecg on admission [ day 4 of illness ] , showing normal pattern ecg on day 8 , when the patient developed sudden hypotension , showing q waves with st elevation in v1-v3 , t inversions in all other leads suggesting anterior wall st elevation mi ecg 30 minutes after thrombolysis with streptokinase [ 15,00,000 units ] laboratory evaluation on admission [ day-4 ] had revealed normal plasma glucose levels , hba1c [ 5.8% ] , serum electrolytes , lipid profile , renal and liver functions . elisa for hiv [ human immunodeficiency virus ] , hbsag [ hepatitis b surface antigen ] and hcv [ hepatitis c virus ] was negative . he was discharged on day-20 with partial recovery of muscle power [ grade 2/5 in all 4 limbs ] on oral hematinics . ivig comprises of gamma globulins derived from purified pooled plasma of thousands of donors , consisting mainly of polyspecific igg . its immunomodulatory and anti - inflammatory actions have enabled its effective use in several autoimmune and inflammatory clinical conditions . adverse reactions are reported in 24 - 36% of patients after high dose [ 2 g / kg ] ivig , most being mild and transient such as headaches , flushing , fever , chills , fatigue , nausea , diarrhea , blood pressure changes and tachycardia . more serious adverse effects like acute renal failure , thrombotic events , aseptic meningitis , hematologic complications and anaphylactic reactions are much rarer . thrombotic complications reported in association with high dose ivig include both venous [ deep venous thrombosis , pulmonary embolism , hepatic veno - occlusive disease ] and arterial events [ acute myocardial infarction , ischemic stroke , thrombosis of arteriovenous fistulae created for hemodialysis , spinal cord ischemia ] , the latter being 4 times more common than the former . thrombotic events are reported in most clinical conditions where ivig has been used , with an estimated incidence of 0.15 - 1.2% per treatment course . arterial thromboses are more commonly associated with atherosclerotic risk factors such as advanced age , smoking , obesity , dyslipidemia , diabetes mellitus , hypertension , renal dysfunction , and prior coronary or cerebrovascular disease and occur early ( 77% within 24 hours ) after ivig administration . venous thromboses occur later ( 54% more than 24 hours after ivig administration ) and are associated with risk factors such as obesity and immobility . autonomic dysfunction [ ad ] in gbs patients per se has been reported anecdotally to cause mi by catecholamine surge and coronary spasm . in our patient , mi followed few days after the initial ad subsided . our patient , unlike other reported cases of mi with multiple atherosclerotic risk factors , did not have smoking , obesity , dyslipidemia , diabetes mellitus , hypertension , renal dysfunction and prior coronary or cerebrovascular disease as risk factors . mi occurred during the fifth day of ivig infusion , in concert with reported timing of occurrence . the infarction was confirmed by electrocardiography , echocardiography and elevated troponin t. proposed mechanisms for thrombosis include some of the following- platelet activation , increased blood viscosity , contamination of ivig with activated coagulation factors , induced arterial vasospasm , production of vasoconstrictive cytokines and vasculitis . ivig products from different manufacturers might differ considerably , and factors such as osmolality , ph and excipient used [ sodium or sugar ] , along with volume load and infusion rates determine the adverse effects . it is thought that salt - based high viscosity products might be responsible for initiation of thrombosis and mi . it is recommended to assess carefully , the overall risk of mi , stroke and venous thromboembolism , along with risk benefit ratio before ivig use . maintenance of hydration , a slower rate of infusion [ 100 mg / kg / hour ] , combined with antiplatelet therapy [ aspirin-300 mg / day ] and anticoagulation [ enoxaparin-1 mg / kg / day ] have been suggested during ivig infusion to reduce ivig - related thrombosis . to conclude , ivig administration in high doses can be rarely associated with thrombotic complications such as acute mi . adequate hydration and slower rate of infusion , along with careful patient selection based on the risk - benefit assessment may reduce this complication .