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Washington University Experience | VASCULAR | Vasculitis - PACNS | 3A0 Case 3 History
Case 3 History ---- The patient is a 40 year-old man with no significant past medical history who was seen at an OSH on 3/29 for worsening headache which woke him from sleep and did not improve with Ibuprofen. Later he presented with intermittent naming aphasia, speaking (but with intact comprehension), spelling and reading with no focal weakness or prodrome. He offered that he had just returned from Jamaica where he was bitten by mosquitos. An extensive work-up was conducted Including a CT of the head (negative) and CT angiogram (negative). An exhaustive meningoencephalitis panel was negative (Zika, Chikungunya, dengue, HSV 1 and 2, West Nile, St Louis). Cytology failed to show malignancy. Repeat MRI showed leptomeningeal and dural involvement of left posterior temporal and inferior parietal lobes. He was treated with Acyclovir for 3 days and was discharged on 04/01. He shortly thereafter presented with 2 episodes of facial droop and the MRI was repeated. He was then transferred on 04\12 to a second hospital for further work-up. On neurologic exam, there were no focal deficits, sensation and position senses were intact without hemi-neglect, aphasia, dysarthria or apraxia noted. An LP showed only mild lymphocytosis (MS panel, paraneoplastic, flow cytometry, infectious [HIV, HTLV, fungi, AFB] all were negative) with negative ANCA. ---- A brain biopsy was ultimately performed on a left parieto-occipital lesion which showed an active granulomatous vascular centered inflammation, mostly non-necrotizing. The differential included granulomatous angiitis and, less likely, neuro-sarcoidosis without systemic involvement. He was started on prednisone 60 mg a day initially, now currently on infliximab and has improved substantially over the last year since the biopsy.
