We report the case of a 74-year-old woman with no known allergies and a medical history of asthmatic bronchitis, hypertension, breast cancer lasting for 5 years, and mitral valve surgery.
The patient was under standard treatment with acenocoumarol, furosem, bisoprolol, panoprolone, enalapril,prazole and oral iron.
The patient reported a three-month history of unilateral occipital headache irradiating to the frontal and temporal area, of oocyte type, which did not respond to usual analgesics and accompanied intermittent hypoxia, claudication of the mandible Kg.
Physical examination revealed mucosal erythema.
No lymphadenopathies were detected.
No other significant findings were found in the rest of the physical examination.
Neurological examination was normal.
Complementary blood tests and cranial computed tomography were requested.
Laboratory tests showed no anemia, but leukocytosis with neutrophilia.
Blood glucose was 128 mg/dl. CRP was 3.99 mg/dl. Globular sedimentation rate (GSR) was 83 mm (in the first hour).
No other laboratory abnormalities were observed.
Cranial CT showed no space-occupying lesions, but an internal frontoparietal cortical hyperostosis.
With the initial suspicion of temporal artery arteritis, corticoid treatment was initiated with methylprednisolone at a dose of 1 mg/kg orally, improving the initial symptoms.
Three days later a biopsy of the temporal artery was performed, confirming the pathological diagnosis.
Forty-eight hours after the biopsy, the patient complained of severe pain in the tongue, with the appearance of an ulcerated lesion in the right hemilingual. Microbiological cultures were performed, with negative results in cervical coagulation and necrosis.
The patient recovered satisfactorily and resolved the lingual lesion spontaneously. She was discharged to follow-up and control the evolution and treatment in external consultations.
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Two months later, the patient came to the emergency department complaining of weakness in the right hemibody and language impairment.
Physical examination revealed right hemiparesis (upper limb motor balance 3-/5 and lower extremity 2/5), global aphasia, right facial paresis and right hemianopsia.
Cranial CT showed an extensive ischemic acute infarction in the territory of the left middle cerebral artery and posterior cerebral artery.
The electrocardiogram showed rhythm of seizures.
In the coagulation study, INR was 1.48.
No other complementary tests such as cerebral magnetic resonance angiography (MRI), transcranial Doppler ultrasound and supraaortic trunks, or echocardiogram (transthoracic or transesophageal) were performed.
The patient was referred to a long-term care facility for intensive rehabilitation.
