headaches and amnesia following embolic showers in newly dia | Figure 1

Montecristo

Neurology Resident

Headaches and Amnesia Following Embolic Showers in Newly Diagnosed ALL

Case Summary

57 yo female, who presented with a new dx of ALL.

Started AL4, complicated with meningitis due to Enterococcus.

Workup revealed multifocal infarcts (DWI+ADC correlation) (image 1,2, 3), thought to be cardioembolic as TEE showed calcified thrombus. CTA was unremarkable.

1 month after, had a bout of Headaches. FUO and inattention. Started on empiric Abx with Tazo and Vanco. HA resolved but inattention continues, flat affect and what it seems anterograde amnesia. Off note, ALL in remission.

New MRI shows hyperintense lesions on T2/flair on deep periventricular WM (image 4,5).

These were not present on previous MRI 1 month before. Therefore, I think, microangiopathic changes unlikely, Ddx are broad at this point, including vasculitis, demyeliation (less likely as no ON, TM symptoms, age) and less likely infectious (no meningismus, no neurofocal deficits.

her neuro exam shows h-nystagmus on ends of gaze, inattention and amnesia. Motor is normal, no long tract signs.

her hippocampus looks normal to me (image 6)

We held her AC to do LP soon.

Will do CTA to for vessel imaging, we are thinking vasculitis higher on our DDx.

Any ideas welcome.

Updates

Update 1

patient remains clinically unchanged, with recurrent headaches rated mild/mod. Afebrile. Alert. Amnestic component still present. CTV neg for CVST. Coag profile normal Viral panel neg CSF showed Leuks 110 (dif: 84% neutrophils, mono 7%). Glucose low 1.8 (mmol/L) Prot high 1.35, lactate 3.5 (high), no xantochromia. Flow cytometry and cytology PND. ID was consulted for Abx therapy. In summary no evidence of vasculitis yet, CSF profile could fit a bacterial/fungal picture, but also CNS malignancy could potentially cause this profile too, thoughts?

Update 2

To finalize this case.... CSF cultures neg, on empirical Tazocin + Vanco. CSF cytometry showed Lymphoblasts 30% (in a context of ALL) Coagulation profile all neg. Clinically better, HA resolved. Repeat Echo, showed unchanged mass (favoured calcified thrombus), on anticoagulation with Dalteparin, Cardio will follow with cardiac MRI. From neuro standpoint, headaches treated symptomatically with Mg and Maxeran, 0/10. To call it a name, ID still thinks it was recurrent meningitis. Changes on MRI thought to be related to that, no evidence found to support vasculitis. Will repeat MRI in 3 months time. Pt clinically well. Thanks for contributing to this case! Sometimes, despite all our efforts, we cannot come to a clear Dx, we tried :)

Diagnosis Added

Recurrent meningitis in a context of newly diagnosed ALL and multifocal embolic infarcts.