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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, Intravascular | 16A0 Case 16 History
Case 16 History ---- This is a 62-year-old hypertensive man who presented with step-wise neurologic decline. Approximately 2 months prior to presentation he developed vertigo, vomiting and spasm of his hand muscles. He presented to an OSH where a brain MRI showed cerebellar and bilateral subcortical strokes. CT angiogram did not identify a cause. He was discharged on Apixaban and aspirin. After several weeks he complained of new headaches and presented to the ED where repeat MRI showed new strokes in multiple vascular territories. A workup for hypercoagulability was negative. He was discharged on a new anticoagulation regimen. He suffered multiple falls at home and developed progressive confusion which interfered with activities of daily living. He was admitted to an OSH where MRI showed radiographic progression of multifocal strokes of varying ages with a normal repeat CT angiogram. Atrial fibrillation was not identified. LP was traumatic but oligoclonal bands were not found and there was a normal IgG index. The patient was negative for fevers, chills, night sweats, weight loss, vision changes, rash/skin changes, oral or genital ulcers, or joint pain/swelling. The patient was transferred to BJH for further workup. He was oriented x1, slow and perseverative, followed only one step commands, had slowed motor function and weakness of the left arm and leg, left hyperreflexia and possible sensory neglect of left arm and leg. Extensive serologic studies did not contribute to a definitive diagnosis. ---- The clinical differential was vasculitis, amyloid beta related angiitis (ABRA), Antiphospholipid Syndrome (antibodies were negative on testing), infectious vasculopathy, reversible cerebral vasoconstriction syndrome (RCVS) and intravascular lymphoma. ---- Review of the outside brain biopsy at BJH demonstrated intravascular lymphoma.
