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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, Intravascular | 12A0 Case 12 History
Case 12 History ---- The patient was a 59 year old woman with a history of non-insulin dependent diabetes mellitus, diabetic retinopathy, possible diabetic neuropathy, and hypertension who presented on 11/2 with a 1-2 month history of increasing weakness, leg swelling, and abdominal pain. Her weakness had gradually progressed over time, although she had a more rapid progression over the last one to two months. She had also complained about numbness and tingling throughout her body, but the symptoms were most pronounced in her lower extremities. She was diagnosed with a left lower lobe pneumonia, proteinuria, and anemia. She was treated with antibiotics, but showed no improvement in weakness. She had additional studies at BJH to evaluate for malignancy including a bone marrow biopsy which was not diagnostic. She had an ESR of 55. Panhypopituitarism involved low LH, FSH, and TSH. She had progressive renal failure which was diagnosed as acute ATN. On 11/27 she responded slowly to questions and appeared to not be oriented to time or place. She had a ptosis along with her left pupil being smaller than her right. She had diffuse weakness. She was noted to have no movements in her lower extremities and decreased response to pain throughout. She had no deep tendon reflexes. She had an LP which showed a CSF protein of 95, a normal glucose, and two cells. On 12/1 she had an episode of ventricular tachycardia and hypotension from which she expired. ---- At autopsy the weight of the unfixed brain was 1450g. Coronal sections of the cerebral hemispheres reveal multiple thin, well-circumscribed, and soft lesions in the periventricular areas and corpus callosum. Malignant cells were also present in the small capillaries within the entire brain parenchyma and were associated with microinfarcts. Malignant cells are found in the endoneurial vessels of the peripheral and cranial nerve roots. Sections of the skeletal muscle from multiple sites show similar involvement of the intramuscular vasculature by neoplastic cells. One micron thick, toluidine blue stained sections of the plastic embedded sural nerve show almost complete loss of myelinated fibers and a marked decrease in the number of unmyelinated axons.
