case_images: PMC11419990_01
case_images: Evolution of clinical presentation, inflammatory biomarkers and imaging findings. (A) The MRIs were unremarkable on three occasions, including when the symptoms were most severe (POD 25) and during the recurrence (POD 38). (B) An acute ischemic stroke at the head of the right caudate (white arrowhead) was seen incidentally on POD 60 when the chorea was resolving. (C) The timing of immunomodulation (yellow) and clinical symptoms (red and green) was plotted against the days after valve replacement. The initial presentation began with cognitive changes (green, POD 7) and chorea (red, POD 14), then with symptom resolution on POD 30 during the pulse steroid (POD 27-31). Oral steroid was stopped on POD 39 with symptoms recurrence around POD 46 and then at maximum around POD 54-55. The second course of pulse steroid lasted from POD 56-60 with significant clinical improvement by POD 58. The inflammatory markers ESR (magenta) and CRP (cyan) were trended (dotted lines denote upper limit of normal range). AVR, aortic valve replacement; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; POD, postoperative day.
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case_images: PMC11419990_01_fimmu-15-1458022-g001.jpg
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case_images: However, his mentation did not improve with time and instead progressed to the extent that, by postoperative day (POD) 7, his family was alarmed by the out-of-character hypervigilance and aggression ( Figure 1C ). Serum hematological, metabolic, and infectious studies were normal, except for the elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) ( Table 1 ,  Figure 1C ). Computed tomographic angiogram and MRI showed no vascular or structural lesions ( Figure 1A , POD 25). Cell counts and glucose in the cerebrospinal fluid (CSF) were normal with protein at the upper limit ( Table 2 ,  Figure 1C ). Figure 1C ). Follow-up MRIs from POD 32 and 38 did not show any significant change ( Figure 1A ). Despite concomitant use of clonazepam 0.5 mg BID and valproic acid 500 mg BID, upon discontinuation of steroid, chorea recurred immediately within the same week (POD 46) along with the elevation of inflammatory markers ( Figure 1C ). The fourth MRI from POD 60 revealed incidentally an acute infarct at the right caudate ( Figure 1B ). He otherwise remained in full remission at his 3, 6, & 9-month outpatient follow-up ( Figures 1C ).