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Washington University Experience | VASCULAR | Infarct - Spinal Cord | 11A0 Case 11 History - Copy
Case 11 History ---- This patient was a 15 year old female who had presented 5 months previously for excision of a right ovarian mass which proved to be Burkitt’s lymphoma, with bone marrow results consistent with mature B cell ALL. She had undergone an initial course of chemotherapy including intrathecal methotrexate, as well as systemic cyclophosphamide, adriamycin, and vincristine. On the present admission she presented with 3 day history of nausea, poor oral intake, shortness of breath, abdominal pain and cutaneous petechiae. At the time of admission she had a peripheral blastic leukocytosis, thrombocytopenia, elevated serum creatinine, and elevated uric acid consistent with tumor recurrence and tumor lysis syndrome. A lumbar puncture was performed revealing elevated opening pressure of 360 mm of water, and an elevated protein at 59, but no cells. She was begun on a chemotherapy regimen including Carboplatin, VP16 and ifosphamide. Overnight of the 2nd day of admission she complained of pain and numbness in her legs. She received Ativan for sedation. The next day she was difficult to arouse and did not appear to move her legs. Neurologic exam at that time revealed a moderately severe global encephalopathy and an areflexic paraplegia. Head MRI and CT scan showed no mass lesion or evidence of elevated intra-cranial pressure, though there were diffuse white matter changes. An MRI of the spinal cord showed no compressive lesion, though there was a question of diffuse expansion of the cord. The patient rapidly developed worsening renal insufficiency and pulmonary edema requiring intubation and mechanical ventilation assisted by sedation and neuromuscular blockade. She was febrile and treated empirically with antibiotics. While paralyzed she developed some pupillary asymmetry with enlargement of the left pupil with respect to the right. They both remained minimally reactive. An EEG showed a burst suppression pattern without evidence for seizure activity or focal findings. As neuromuscular blockade was withdrawn she slowly regained all appropriate brainstem reflexes and her mental status improved. She had a persistent areflexic paraplegia. Her urine output and renal function improved for several days. However, over a 24 hour period she became progressively hypotensive and anuric with low grade fever and cultures of blood, urine, and bronchoalveolar lavage grew enterobacter. Pressor support was withdrawn, she became asystolic, and died. ---- Autopsy showed extensive hemorrhage involving the subdural and subarachnoid space with compression and infarction of the underlying cord extending from the lower thoracic to sacral cord. The blood in the subdural space surrounding the spinal cord may have caused edema and infarction by profound vasospasm and/or direct compression of spinal vessels.
