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Washington University Experience | MYELIN (IMMUNE-MEDIATED) | Sentinel & Steroid Rx Lesions | 1A0 Case 1 History
Case 1 History ---- This 38 year old woman was initially admitted to an outside hospital with the new onset of seizures. The patient had been having difficulty with balance and gait, along with personality changes, memory problems, increasing sleepiness, headaches, and difficulty with language. A head CT showed a left temporoparietal lesion with moderate edema but no midline shift or mass effect. The patient was started on Dilantin and Decadron and transferred to our hospital for further evaluation. The patient underwent lumbar puncture which revealed an opening pressure of 8 cm of water, 43 total cells (95% lymphocytes, 5% monocytoid cells, none malignant). glucose 71 mg%, protein 62 mg/dl with no oligoclonal bands. The patient underwent a brain biopsy (images #1A1-3) during this admission which was interpreted as consistent with a demyelinative process. The patient was discharged home after receiving IV Solumedrol. Search for a metastatic neoplasm was nonproductive. MRI showed at least four enhancing lesions and one month later revealed a large enhancing lesion extending from the right internal capsule into the brainstem which was thought consistent with tumefactive multiple sclerosis. Approximately 5 months later she was admitted to the neurology service for nearly a month of treatment, complaining of worsened mental status and weakness, urinary retention, incontinence, visual deficit, and recurrent seizures. The patient's mental status waxed and waned and Cytoxan was begun. She continued to have a stormy course and at her last admission, neurologic exam at that point revealed a patient who had eyes closed and would not open to pain, had flexion withdrawal of the bilateral upper extremities to central pain, cranial nerve dysfunction resulting in a right pupil which was 5 mm and fixed, a left pupil which was 2 mm and fixed, questionable papilledema, positive doll's eyes reflexes and symmetrical facial appearance. A head CT was obtained at that point which was interpreted as multiple mass lesions bilaterally with significant edema, midline shift to the left and transtentorial herniation along with hydrocephalus. Because of the patient's poor prognosis a decision was made to give comfort care and the patient died soon thereafter. Postmortem examination was performed (images 1B-F).
