Follow the Bouncing Ball: A Patient Case

Stephen Paget, MD


February 20, 2013

Case Presentation

Other than hypertension and diabetes, this 75-year-old male patient was generally well until May 2011 when he developed an onset of fever, severe fatigue, marked weight loss, general weakness, night sweats, aches and pains in his shoulders and knees, anemia, and a markedly elevated sedimentation rate, followed closely by a cerebellar cerebrovascular accident presenting with blurred vision and balance problems. The patient was hospitalized and had an extensive workup including MRIs of the brain that confirmed a cerebellar stroke. He was found to have T5 thoracic spine bony lesions, but 2 attempts at needle biopsy showed no tumor or infection.

The patient had a total-body PET scan in June 2011 which showed mild to moderate hypermetabolic changes in the femoral and popliteal arteries and changes in the shoulders consistent with soft tissue inflammation. MRA of the brain in June 2011 revealed no significant vascular abnormalities in the posterior circulation. In the summer of 2011, all of the patient's systemic manifestations cleared completely without steroids or antibiotics, and he went back to work 1 month after his stroke. Over the next 6 months he developed numbness and tingling in the fingers and toes as well as a bluish discoloration in his toes when his feet were dependent. Gabapentin was given for his peripheral neuropathy but this led to fatigue, rashes, and sweating and was therefore stopped.

Follow-up brain MRA in January 2012 showed vascular changes consistent with rapidly progressive atherosclerosis or vasculitis in the posterior circulation. The patient was seen for a routine visit by an ophthalmologist who found vasculitic retinal lesions. Temporal artery biopsy was negative bilaterally.

He was referred to me for evaluation and treatment. Other than pins and needles and decreased pin-prick and touch sensation in his feet, mild hand aches and pains, and fatigue, he said that he felt fine and was working 16 hours a day as a chauffeur. He wondered why he was there to see me. His ESR was 35 with a CRP of 3. All lupus serologies and C3 and C4 complement levels were normal. ANCA was negative. Urinalysis showed no proteinuria. Chemistry screen was normal.