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Washington University Experience | VASCULAR | Infarct - Remote | 15A0 Case 15 History
Case 15 History ---- This patient was a 71 year old right handed man with NHL s/p chemo (Rituxan) in 2006 (currently in remission), GERD, hyperlipidemia, s/p TIAs and a right MCA stroke approximately 6 months prior, s/p bilateral DVT on anticoagulation who was admitted for workup of possible systemic vasculitis. After the stroke, he continued to have persistent left facial and jaw pain that was not responding to pain medications and had a high ESR of 120. He was then readmitted in 8/08 with sudden bilateral leg weakness and urine incontinence and was found to have bilateral DVTs. Spinal MRI in BJH showed mild multilevel degenerative disc disease in the cervical, thoracic, and lumbar spine. This was most severe at L3-4 and L4-5 with mild central canal stenosis and bilateral neural foraminal narrowing secondary to generalized L3-4 and L4-5 disc bulges. Head CT showed chronic right basal ganglia and bilateral thalamic infarcts. He was then treated empirically for giant cell arteritis with IV steroids and discharged to rehab on oral steroids. In rehab, he started having low grade fevers with shortness of breath and fatigue and was readmitted in respiratory failure in 10/08. At that time, he had a temporal artery biopsy that was negative (had been on steroids for 6 weeks). His physicians favored a systemic vasculitis such as Wegener’s. He was ANCA neg. ANA +1: 160. Infection and metastasis could not be ruled out. He decompensated due to bleeding from a right gluteal hematoma that could not be embolized. He was then later stabilized but required multiple transfusions. Later in the course, his mental status deteriorated and he became thrombocytopenic. ---- General autopsy findings included focal remote and acute myocardial ischemic changes and necrotizing lobar pneumonia. There was no evidence of vasculitis
