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Washington University Experience | VASCULAR | Infarct - Embolic | 1A0 Case 1 History
Case 1 History ---- This 65 year old woman was apparently in good health until 1978 when she developed symptoms of congestive heart failure which worsened in February of 1979 combined with dressing apraxia and confusion. While hospitalized she was discovered to have 4+ proteinuria and a moderate pericardial effusion; however, a collagen vascular workup including temporal artery biopsy were all negative. CT scan showed multifocal cerebral vascular disease. She was admitted to BJH in April 1979. Her exam showed a 3 out of 6 holosystolic murmur heard in the left peristernal border in the apex radiating to the axilla and also a 2 out of 6 systolic ejection murmur at the right peristernal border. Renal biopsy showed membranous glomerulonephritis. Ophthalmology consult for complaints of burning, itching eyes, and decreased hearing and salivation was thought to represent Sjogren’s syndrome. Neighbors visiting one day found her unable to talk to them. CT scan done on 7/13 revealed areas of decreased density within the right and left parietal lobes and in the right frontal lobe, all without enhancement or mass affect. The patient continued to be lethargic with worsening congestive heart failure and anasarca. On 7/31 she again had an episode of hypotension and, later that day, cardiac arrest and died. ---- At autopsy microscopic examination of the main cerebral arteries and microscopic intra- parenchymal arteries and arterioles showed recent microscopic thromboemboli within arteries diffusely and in greater numbers adjacent to the cystic lesions of the left parietal occipital lobe. The general postmortem examination revealed a single vegetation attached to the atrial surface of the mitral valve, whose histologic appearance was consistent with non-bacterial thrombotic (“marantic”) endocarditis. Thromboemboli occluding small arterioles were superimposed upon minimally atherosclerotic non-vasculitic cerebral arteries and arterioles.
