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canp2019c03

Case 3

JA Sonnen

The Montreal Neurological Hospital and Institute, McGill University

Clinical Summary:

The decedent was a 60-year-old man with chronic kidney disease secondary to diabetes and hypertension who presented with volume overload and urinary retention. In the weeks before presentations he had placement of an AV fistula for dialysis. He was dialyzed in the hospital which improved his fluid status, however while in the hospital, he developed lower-limb numbness and weakness, bowel/bladder incontinence with a sensory level around T2. MRI of the cord showed at T2 bright, diffusion restricted lesion involving both grey and white matter at T2-T3. There was clinical concern for a vascular access steal syndrome. Over the next 2 weeks the patient became encephalopathic. Subsequent imaging demonstrated multiple spinal cord and brain lesions seen on imaging, of unknown etiology. There was clinical suspicion for vasculitis and sepsis. Cerebral angiography was equivocal. Blood cultures were negative. Over the course of two months the patient’s encephalopathy progressed and he developed progressive multiple organ dysfunction and died on hospital day 65.

Material submitted:

  1. Virtual slides of autopsy frontal lobe (H&E and H&E-LFB)
  2. MRI images, Axial FLAIR and Axial  DTI (below)

Questions:

  1. What unique information does MRI-DTI imaging reveal?
  2. What is the underlying process?
  3. Would immunohistochemistry be helpful? What would be most useful?
  4. What is the treatment and prognosis?