An 80-year-old patient was admitted to the internal medicine department for binocular diplopia and hearing loss with sudden onset. The patient had presented with SARS-CoV-2 infection 3 weeks previously and had been admitted to hospital. Complete work-up including autoimmunity, serum and LCR viral serology and MRI did not allow a diagnosis to be established. The hypothesis of a microvascular origin or the previous SARS-CoV-2 infection was considered. The latter was retained in light of the temporal relationship, the absence of other pathologies after exhaustive work-up, and the clinical evolution.
An 83-year-old woman was admitted to the emergency department for a 7-day history of fatigue and progressive cyanosis in the feet and hands after cold exposure despite physical protective measures. Upon arrival, the patient presented with necrotic cutaneous lesions in both hands and distal lower extremities. Upon admission, hemoglobin was 7.6 g/dL and laboratory tests were consistent with cold agglutinin disease (CAD), the presence of monoclonal IgM, and flow cytometry consistent with lymphoplasmacytic lymphoma, but MYD88 L265P mutation was negative. The patient required blood transfusion, resulting in stabilized hemoglobin and a decrease in markers of hemolysis. Treatment with aspirin 250 mg daily and intravenous iloprost 0.5 mL/h was initiated with a poor clinical response at day 4. Amputation was required. Plasma exchange was performed and chemotherapy with rituximab and bendamustine was initiated. The clinical course was marked by further necrosis, prompting discussions regarding an additional amputation that was not performed considering the high surgical risk and refusal by the patient. Supportive treatment was initiated, and the patient expired one month after hospital admission.
A 54-year-old woman was admitted to the emergency department for an acute, fluctuating altered mental status and reduced perceptual awareness of her surroundings as well as disorganized thinking. Blood tests, including for drugs, were normal. A CT scan of the brain was normal. Magnetic resonance imaging and CT angiography of the supra-aortic vessels were both were consistent with moyamoya disease. The patient was hospitalized for further investigations.
A 74-year-old patient anticoagulated with rivaroxaban for chronic atrial fibrillation presented to the emergency department with acute lumbar pain with progressive weakness of the lower limbs and inability to stand up. No previous trauma was reported. Neurological examination was consistent with a complete spinal cord syndrome at the level of T6. Magnetic resonance imaging showed the presence of spinal cord compression associated with signs of extensive intramedullary inflammation secondary to a haematoma. The patient underwent thoracic laminectomy with evacuation of an intradural haematoma. No intraoperative complications were described, but no clinical improvement had been achieved 15 days after the surgical intervention.
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