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Washington University Experience | MYELIN (NON-IMMUNE MEDIATED) | Central Pontine Myelinolysis (CPM) | 3A0 Case 3 History
Case 3 History ---- The patient was a 54-year-old woman with a history of multiple sclerosis (beginning in April 2003 with lower extremity weakness, paresthesias of the lower extremities and balance difficulties). The patient presented in May 2005 with nausea, vomiting and abdominal distension having lost weight (20 pounds over 2 months). Lymph node biopsy demonstrated malignant B-cell lymphoma. Post-operatively, the patient improved, but 1 month later started to develop slowly progressive mental decline, characterized by sleepiness, dysarthria and generalized weakness. Admitted on 7/11/05 to work up these symptoms, she was seen by Neurology who concluded that mental status changes were caused by hypercalcemia, acute renal failure and possible meningeal involvement. The patient began chemotherapy with rituximab, cyclophosphamide, mesna, doxorubicin, vincristine and intrathecal cytarabine. Subsequently, the patient developed pancytopenia, then suffered respiratory failure and was intubated. Finally, the patient developed Stevens-Johnson syndrome (most probably secondary to rituximab or allopurinol) with a gastrointestinal bleed, mucositis and bilateral corneal abrasions. She developed a neutropenic fever due to enterococcus bacteremia. The patient received multiple blood transfusions. At the end of this complicated course, she was extubated and transferred back to the floor on 8-10. On 8-13 she developed cardiopulmonary arrest from which she was resuscitated and was transferred to the intensive care unit. She was found to have pupillary abnormalities and myoclonus. Head CT scan showed a right-sided subdural hematoma, with 4 mm midline shift. Also there was decrease of grey-white matter differentiation and a hypodensity of central pons. The conclusion was that the patient had suffered anoxic brain injury and for that reason received terminal wean, extubation, morphine drip on 8-18 and died.
