case_images: PMC6664498_01
case_images: T2-weighted MRI without contrast images of the brain. The hyperintense areas reflect areas of ischemia. These were reviewed as recent infarcts in the ACA, MCA, and PCA territories. No intracranial hemorrhage can be identified. The radiologist also noted a mild mass effect with no midline shift.
case_images: CRIM2019-2320751.001.jpg
case_images: PMC6664498_01_CRIM2019-2320751.001.jpg
case_images: fig1
case_images: This revealed multifocal areas of recent ischemic infarction involving large areas of the bilateral posterior cerebral artery (PCA) territories, the left middle cerebral artery (MCA) territory, and small infarcts in the right anterior cerebral artery (ACA) and bilateral watershed areas (Figures 1 and 2).
case_images: Magnetic resonance angiography (MRA) images of the head and neck are shown. The top 3 panels show MRA of the head, reviewed as multifocal areas of irregularity and narrowing within the anterior and posterior circulations, including pronounced stenosis of the bilateral carotid termini, middle cerebral arteries, right ACA A1 segment, and right PCA P3 and P4 segments with nonvisualization of the mid to distal right and P4 segment. The bottom panels show MRA of the neck, which was reviewed as unremarkable.
case_images: CRIM2019-2320751.002.jpg
case_images: PMC6664498_01_CRIM2019-2320751.002.jpg
case_images: fig2
case_images: This revealed multifocal areas of recent ischemic infarction involving large areas of the bilateral posterior cerebral artery (PCA) territories, the left middle cerebral artery (MCA) territory, and small infarcts in the right anterior cerebral artery (ACA) and bilateral watershed areas (Figures 1 and 2).
case_images: Peripheral blood smear shows pancytopenia with paucity of leukocytes, erythrocytes, and platelets. A neutrophil with cytoplasmic toxic granulations and adjacent platelet is seen (Wright-Giemsa, original magnification x 100).
case_images: CRIM2019-2320751.003.jpg
case_images: PMC6664498_01_CRIM2019-2320751.003.jpg
case_images: fig3
case_images: The peripheral blood smear revealed decreased white blood cells, few neutrophils which were hypolobulated and hypergranular; normocytic normochromic red blood cells, rare polychromasia without tear drop cells; and decreased platelets, without clumping (Figure 3).