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Washington University Experience | VASCULAR | Infarct - Embolic | 8A0 Case 8 History
Case 8 History ---- The patient was a 33 year old woman who was admitted on 11-6 with a two day history of increasing confusion and died 9 days later. The overall clinical impression was that she had thrombotic thrombocytopenic purpura (TTP) and also possibly SLE with multiple organ system involvement including CNS, renal, and cardiovascular. The patient had been relatively healthy up until about four weeks prior to her admission when she had a right middle cerebral artery territory infarct. A cerebral angiogram showed an embolus lodged in the right middle cerebral artery, thought to be consistent with an embolic event. She was put on Coumadin and had good recovery of her left-sided weakness. The patient was doing well until two days prior to this admission when she developed progressive lethargy and confusion. She presented to the ER on 11-6. Her initial exam revealed that she was lethargic and confused. Otherwise, her neurologic exam was non-focal. Her general exam was also unremarkable; specifically, there were no skin lesions noted. Initial laboratory work-up showed severe acute hemolytic anemia, thrombocytopenia and acute renal insufficiency. Plasmapheresis and IV steroids were started. During her ICU stay she was lethargic and confused, but was able to follow commands and was intermittently oriented to time, person, and place. She had a head MRI on 11-10 which showed that, in addition to the resolving right MCA territory infarct, she had a new ischemic infarct in the region of the right basal ganglia. TTE and TEE revealed severe mitral valve regurgitation and small vegetations at the tip of the mitral valve. These echocardiogram findings combined with high titer of ANA were thought to be consistent with SLE and Libman-Sacks endocarditis. Her neurologic status stabilized and her renal function improved to some extent after initial worsening. She remained relatively stable until 11-14 when her mental status worsened. She became lethargic and unable to follow commands. No focal weakness was identified. An emergent head CT was obtained which revealed a new left posterior parietal-occipital infarct. She was again transferred to the medical ICU. On 11-15 in the early morning she was found pulseless and was pronounced dead after unsuccessful CPR. ---- Autopsy showed multiple infarcts of varying ages frontal, parietal, temporal, and occipital neocortices. In the left frontal lobe there is a small cortical infarct which is located in the depth of a sulcus.
