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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, Intravascular | 18A0 Case 18 History
Case 18 History ---- The patient was a 64 year old woman with a past medical history including hyperlipidemia, type 2 diabetes mellitus, acquired hypothyroidism (S/P Graves disease 1997 radioablation), and two cerebrovascular incidents 1-2 months prior to death thought to be due to antiphospholipid syndrome, prompting outpatient warfarin therapy. She developed bilateral lower extremity weakness. Imaging (MRI and CT) showed T1-T2 myelitis. She received IV methylprednisone and 1 dose of IV immunoglobulin on 9/5 due to concern for a demyelinating process. She became hypotensive and hypothermic, and was transferred to the BJH NNICU on 9/11. Upon arrival at BJH, the clinical team confirmed her upper extremity weakness, and imaging showed cortical lesions thought to be inflammatory in nature (potentially an active demyelinating process related to her transverse myelitis). She underwent one session of plasmapheresis for her presumed transverse myelitis. The differential diagnosis was broad at this time, including demyelinating disease, neoplasia, neurosarcoidosis, nutritional myelopathy, and infarction. A new brain MRI on 9/18 showed interval increase in size and number of lesions in the bilateral subcortical white matter. There was interval development of a diffusion-restricting lesion in the midline splenium corpus callosum, concerning for a new infarct vs cytotoxic lesion. The decedent became unresponsive with encephalopathy and agonal breathing and passed on 9/25.
