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Bratu IF, Ribigan AC, Mihailă-Bâldea S, Badea R, Stefan D, Davidoiu C, Casaru B, Antochi F. Febrile episode unmasking neuropsychiatric systemic lupus erythematosus with lytic lesions caused by secondary autoimmune myelofibrosis: Case report. Medicine (Baltimore) 2021; 100:e28251. [PMID: 34941099 PMCID: PMC8702261 DOI: 10.1097/md.0000000000028251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/25/2021] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is characterized by numerous immunological abnormalities that lead to multiorgan involvement. Central and peripheral nervous system manifestations are present in 8% to 92% of the cases of SLE. Furthermore, there have been reported cases of secondary autoimmune myelofibrosis associated with SLE. PATIENT CONCERNS We present the case of a 64-year-old female who was transferred from the Cardiology Department, where she was admitted for pericardial-pleural-peritoneal effusion after being discharged from another hospital following the resolution of a febrile episode. During hospitalization, she presented multiple oculomotor nerves palsies and weakness in the lower limbs. Serial cerebral magnetic resonance imaging (MRI) revealed extensive cerebral venous thrombosis. Nerve conduction studies showed sensory-motor axonal polyneuropathy. Thoracic MRI revealed a rare finding in patients with SLE - lytic lesions. DIAGNOSES Extensive clinical, imaging, blood, and urine tests were performed. The patient exhibited pancytopenia, elevated inflammatory markers, hyperhomocysteinemia, mild hypoproteinemia, and severe proteinuria. The Hematology consultation ascertained that the peripheral blood smear and the bone marrow aspiration showed no alterations suggestive for a primary hematological disease and the thoracic vertebral-medullary MRI changes had a very low probability of representing osteolytic lesions in the context of plasma cells dyscrasia, but could not exclude their being result of a secondary autoimmune myelofibrosis. Immunology blood tests highlighted the presence of antinuclear antibodies and lupus anticoagulants. In this context, the Rheumatology consultation established the diagnosis of SLE with multiple complications. INTERVENTIONS The patient received treatment with cyclophosphamide. OUTCOMES The ocular motricity problems and the paraparesis showed improvement. However, 1 week later, the patient developed weakness, dyspnea, and right lower quadrant abdominal pain. The abdominal-pelvic computed tomography scan indicated an acute right retroperitoneal hematoma with active bleeding for which she underwent arterial embolization of the spinal lumbar arteries with optimal result, but she died a few days later. LESSONS We chose to present this case in order to highlight the importance of interdisciplinarity in diagnosing and managing patients with SLE and multiorgan ailments, especially when faced with rare constellations of complications such as extensive cerebral venous thrombosis and osseous lytic lesions caused by secondary autoimmune myelofibrosis.
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Affiliation(s)
- Ionuţ-Flavius Bratu
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
| | - Athena Cristina Ribigan
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Sorina Mihailă-Bâldea
- Department of Cardiology, Bucharest Emergency University Hospital, Splaiul Independentei, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Badea
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniela Stefan
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Davidoiu
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
| | - Bogdan Casaru
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
| | - Florina Antochi
- Department of Neurology, Bucharest Emergency University Hospital, Bucharest, Romania
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Ribigan AC, Badea RS, Ciocan A, Stefan D, Casaru B, Ioan P, Antochi F, Băjenaru O. Moyamoya-like vasculopathy associated to MYH9-related thrombocytopenia manifested by multiple cerebral ischemic lesions: a case report. BMC Neurol 2020; 20:352. [PMID: 32950057 PMCID: PMC7501715 DOI: 10.1186/s12883-020-01927-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022] Open
Abstract
Background Moyamoya-like vasculopathy (MMV) and myosin heavy chain 9-related platelet disorders (MYH9-RPDs) or macrothrombocitopenias are rare syndromes. Their association is even more infrequent. Case presentation A 29-year-old female with history of MYH9-RPD, presented to our department for episodes suggesting transient ischemic attacks. Based on the imaging studies that revealed multiple ischemic lesions and stenoses of both distal internal carotid arteries and the arteries of the circle of Willis, the diagnosis of MMV was established. The treatment with Verapamil was initiated, leading to symptom remission. Two months later, the patient presented one episode of dysarthria, followed by involuntary movements of the right upper limb, few days later. Long-term electroencephalogram monitoring depicted epileptiform abnormalities. Resolution of symptoms was obtained after increasing the dose of Verapamil, and initiating Levetiracetam. Conclusions This is an interesting case of a patient with two rare pathologies, who presented with cerebral ischemic strokes. To our knowledge there are few cases described in the literature presenting with cerebral hemorrhagic events but none of them with multiple cerebral ischemic lesions. As these cases are very rare, it is important to gather evidence regarding the best approach and treatment strategy.
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Affiliation(s)
- Athena Cristina Ribigan
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania. .,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila Bucharest, Dionisie Lupu street, number 37, district 1, 020021, Bucharest, Romania. .,Transcranial Doppler Monitoring and Neurosonology Laboratory, Romanian Academy, Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania.
| | - Raluca Stefania Badea
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila Bucharest, Dionisie Lupu street, number 37, district 1, 020021, Bucharest, Romania.,Transcranial Doppler Monitoring and Neurosonology Laboratory, Romanian Academy, Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Alida Ciocan
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Dana Stefan
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Bogdan Casaru
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Patricia Ioan
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Florina Antochi
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania.,Transcranial Doppler Monitoring and Neurosonology Laboratory, Romanian Academy, Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
| | - Ovidiu Băjenaru
- Neurology Department, University Emergency Hospital Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila Bucharest, Dionisie Lupu street, number 37, district 1, 020021, Bucharest, Romania.,Transcranial Doppler Monitoring and Neurosonology Laboratory, Romanian Academy, Bucharest, Splaiul Independentei, number 169, district 5, 050098, Bucharest, Romania
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