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Washington University Experience | VASCULAR | Infarct - Spinal Cord | 3A0 Case 3 History
Case 3 History ---- The patient was a 71 year old man with Non-Hodgins Lymphoma S/P chemotherapy with Rituxan in 2006, currently in remission, hyperlipidemia, restless legs syndrome, s/p TIAs and right MCA stroke in May 2008. MRI of the T/L spine was normal in 2008, i.e., had no evidence of cord infarction. 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 (120). He was then readmitted in 8/08 with sudden bilateral leg weakness and urinary incontinence and was found to have bilateral DVTs. Spinal MRI in BJH showed mild multilevel degenerative disc disease in the cervical, thoracic, and lumbar spines which was most severe at L3-4 and L4-5, where there was mild central canal stenosis and bilateral neural foraminal narrowing secondary to generalized L3-4 and L4-5 disc bulges. An infrarenal abdominal aortic aneurysm, measuring up to 3.3 cm in greatest diameter was also discovered. Brain MRI showed nonspecific T2 hyperintensities and CT showed chronic right basal ganglia and bilateral thalamic lacunar infarcts. He was then treated empirically for giant cell arteritis with IV steroids and discharged to rehab on oral steroids. In rehab, he had low grade fevers with SOB 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) and ESR was 120 while on steroids (ANCA neg. ANA +1: 160). A 4 mm pulmonary nodule in the right lower lung lobe. Pulmonary and Rheumatology Divisions’ impression was a systemic vasculitis such as Wegener’s granulomatosis. 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. He had an EMG/NCT that showed axonal sensorimotor neuropathy and his SPEP/UPEP were positive for IgM K consistent with a paraproteinemic neuropathy. The exact antemortem diagnosis remained unknown.
Autopsy showed microinfarcts in multiple vascular territories in the CNS and spinal cord. The apparent abdominal aneurysm proved to be an aortic dissection with organized thrombus (3.5 cm in greatest dimension) in the presence of extensive atherosclerosis.
