Night Sweats and Paraparesis

A 78-year-old man sought care for saddle anesthesia, left lower extremity numbness, and bilateral lower extremity weakness. The sensory loss occurred suddenly, starting initially in the left perianal region and over the course of 3 hours extending down to involve the entirety of the left lower extremity. Symptoms were stable until 3 weeks later, when he had a few episodes of urinary incontinence. Diffuse, severe, bilateral, lower extremity weakness developed. The patient reported 6 months of intermittent night sweats. Serum studies were notable for pancytopenia and increased erythrocyte sedimentation rate and levels of ferritin and lactate dehydrogenase. Lumbar puncture showed a mildly increased protein concentration with normal blood cell count, glucose value, and cytologic and flow cytometry findings. Magnetic resonance imaging showed multifocal regions of increased T2 signal throughout the central nervous system including the cerebrum, cerebellum, upper cervical cord, lower thoracic cord, and conus medullaris. Gadolinium enhancement was present in the corpus callosum, cerebellum, and dorsal lower thoracic cord. One week later, 18F-fludeoxyglucose–positron emission tomography/computed tomography showed patchy 18F-fludeoxyglucose activity in the cerebral parenchyma, as well as 2 cutaneous, 18F-fludeoxyglucose-avid soft-tissue nodules. Fine-needle aspiration of 1 of these nodules indicated diffuse large B-cell lymphoma, with no dysplastic abnormalities identified on subsequent bone marrow biopsy. Incisional biopsy of the second soft-tissue nodule showed foci of diffuse large B-cell lymphoma adherent to the lumina of a few small arteries, consistent with a diagnosis of intravascular lymphoma. The patient was diagnosed with intravascular large B-cell lymphoma. At initial evaluation at an outside facility, empiric intravenous corticosteroids were administered. After the biopsy findings of intravascular large B-cell lymphoma, he was started on intermediate-dose methotrexate followed by rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy. He continued to experience severe, bilateral, lower extremity weakness and sensory loss. Two months after diagnosis of intravascular large B-cell lymphoma, he died of medical complications from chemotherapy. Intravascular lymphoma is a rare lymphoma subtype that is typically of B-cell origin. The neoplastic cells preferentially grow within the lumen of blood vessels, potentially due to a lack of cellular machinery required for cellular extravasation and parenchymal invasion.

Thyrotoxicosis: A Primary Cause of Arrhythmias and Acute Heart Failure

Thyrotoxicosis results from excessive thyroid hormone and may occur in Graves’ disease, multinodular goiter, and thyroiditis. The association of hyperthyroidism with the worsening of pre-existing heart disease is very well recognized. Additionally, hyperthyroidism can also cause primary cardiac disease including arrhythmias and congestive heart failure. We present a 65-year-old female with a past medical history of intermittent palpitations who came to the emergency department with shortness of breath and bilateral lower extremity swelling. Physical exam revealed an anxious woman with bilateral proptosis, jugular venous distention, bibasilar crackles, and bilateral lower extremity edema. Laboratory data was significant for a brain natriuretic peptide level of 1,930. Chest x-ray revealed vascular congestion. Transthoracic echocardiogram showed an ejection fraction of 63% and diastolic dysfunction. She was admitted and received diuretics for acute heart failure. She developed atrial fibrillation with a rapid ventricular response, managed with a diltiazem infusion and anticoagulation. This event prompted thyroid evaluation which showed a thyroid-stimulating hormone (TSH) of 0.01mU/L, elevated free T4 at 3.37ng/dl, free T3 at 5.8pg/ml, positive Thyroid-stimulating immunoglobulins (TSI) 473%, and thyroid peroxidase (TPO) antibodies 158U/ml. Her symptoms improved after treatment with methimazole. The heart is susceptible to hyperthyroidism due to multiple thyroid hormone receptors on cardiac myocytes causing high sympathetic stimulation from an increased number of myocardial beta-cell receptors. Atrial fibrillation occurs in 10 to 20% of patients with hyperthyroidism and is prevalent among the elderly population. People 60 years and above with a low serum thyrotropin concentration are at a threefold higher risk of developing atrial fibrillation in the subsequent decade. Complications such as cerebrovascular accidents occur in about 14% of cases. About 6% of thyrotoxic individuals develop heart failure secondary to a tachycardia mediated mechanism, leading to an increased level of cytosolic calcium during diastole. This causes reduced ventricular contractility and diastolic dysfunction, often associated with tricuspid regurgitation. Graves’ disease is an autoimmune process characterized by hyperthyroidism due to circulating autoantibodies. TSI binds to and activates thyrotropin receptors, causing the increased synthesis of thyroid hormones. If left untreated, Graves’ disease can lead to severe thyrotoxicosis. Clinicians should be aware of this disease association and ensure thorough clinical investigation, prompt diagnosis, and treatment of thyrotoxicosis to avert these life-threatening events.

Congenital Inferior Vena Cava Agenesis with Ulceration and Deep Vein Thrombosis

Objectives: This is one of the few case reports of congenital inferior vena cava atresia (IVCA) with extensive bilateral lower extremity ulcers. Background: IVCA is a congenital anomaly characterized by poor venous return in the lower extremities with increased risk of deep vein thrombi (DVTs) and, rarely, non-healing ulcers. Results: A 45-year-old woman with history significant for DVTs presented with extensive bilateral lower extremity ulcers, and a CT scan revealed congenital IVCA. Oedema management, DVT prevention, routine wound care and skin grafts resolved the ulcers. Conclusion: Congenital venous abnormalities should be included in the differential diagnosis of multiple unprovoked DVTs and non-healing ulcers.

The Impact of Lymphedema Therapy on Quality of Life: A Case Report

Background and Purpose: Lymphedema is a chronic inflammatory lymphostatic disease known as the buildup of lymph fluid in the fatty tissues that can cause swelling and discomfort in the arms, legs, face, neck, trunk, abdomen, and genitals [1]. Failure of the lymphatic system causes lymphedema [1]. Lymphedema may reduce the quality of life and may progress as well as cause other complications such as cellulitis if untreated [1]. Although there is no cure for lymphedema, there are interventions to reduce or manage the swelling and the discomfort [1]. The purpose of this study is to show that a patient with lymphedema can improve their quality of life significantly with adequate lymphedema therapy interventions using Complete Decongestive Therapy (CDT). Method and Procedures: A 47-year-old African American female patient presented to outpatient physical therapy with a report of experiencing bilateral lower extremity swelling for about ten years. To determine the effects of the treatments, the lymphedema therapist examined the patient using the following tests and measures and outcome measurement tools: Bilateral Girth Measurements, the Lymphedema Life Impact Scale Version 2 (v2), and the Global Rating of Change (GRoC) Scale. The patient attended physical therapy sessions 2 times per week for 3 weeks not including the date of initial evaluation. Thus, the patient attended five treatment sessions. The patient actively participated in the creation of the current goal: to decrease bilateral lower extremity swelling. Results: On discharge assessment (6th visit), the patient reported a reduction in pain to (3/10). The patient scored a 12/68 on the Lymphedema Life Impact Scale (v2) indicating that her quality of life had improved significantly within the past three weeks since receiving lymphedema therapy services. The patient made excellent progress, demonstrated marked improvements with involved extremities lymphatic circulation, and decreased swelling with girth measurements. The patient reported significant improvements with functional activities of daily living such as standing, sitting to standing, and walking. The patient also reported that her quality of life improved significantly.