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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, Intravascular | 5A0 Case 5 History
Case 5 History ---- This patient was a 79 year old man with a prior medical history of bilateral carotid endarterectomy (2003), coronary artery disease s/p stenting (2006), sensorineural hearing loss s/p cochlear implants (2011), benign positional vertigo, and low-grade lymphoma with hemophagocytic syndrome diagnosed in October 2011 treated with steroids. He presented with weakness, balance instability and thrombocytopenia in May 2012. Initial laboratory assessment showed a WBC of 7.1, anemia of chronic disease and thrombocytopenia with a platelet count of 70K. The patient was worked up for possible persistent lymphoma. Bone marrow biopsy showed "normocellular marrow with trilineage hematopoiesis with chronic lymphocytic leukemia/small lymphocytic lymphoma and rare hemo-phagocytosis." Per review of the medical record, the patient was noted to be hyponatremic with a concern for SIADH. Water restriction was initiated. In the last 36-48 hours of his life his mental status was increasingly altered. He became unable to speak with question of an unwitnessed seizure and postictal state; however, EEG on 5/15 showed "no epileptiform discharge" and only generalized slowing. Head CT scans (5/14 and 5/16) showed no acute abnormalities. An LP (5/15), showed elevated protein at 179 and glucose of 53. Cell count: 55 RBC, 4 nucleated cells, 5% PMNs, 86% lymphocytes, and 9% monocytes. CSF cytology (5/20) was reported as "negative for malignancy." CSF (5/15) was negative for infectious organisms including viruses. Carotid Doppler exam performed on 5/17 showed less than 50% obstruction in the right and left common, right and left external, and left internal, with up to 79% obstruction of the right internal carotid. On 5/19 the patient was noted to be hypotensive (BP 82/62) with prerenal acute renal failure. On 5/20 he was found unresponsive, hypotensive with BP 76/30s, and oxygen saturation of approximately 56%. Chest compressions were initiated with ALS protocol. The patient's rhythm on EKG was asystole throughout CPR efforts without pulse. Date of death was 5/20. ---- At autopsy the weight of the unfixed brain was 1520g whose most immediate cause of death was bronchopneumonia. The leptomeninges were cloudy and thickened over the frontal lobe; however, the most substantial neuropathology involved the pituitary gland.