A schizophrenic patient with cerebral infarctions after hemorrhagic shock
A 33-year-old male, who had been diagnosed with schizophrenia and given a prescription for 7.5 mg Olanzapine, was discovered to have multiple sites of self-inflicted bleeding after cutting his wrists. He had a past history of Kawasaki disease, which had completely resolved when he was a child. When the emergency medical technicians checked him, he was conscious, but in shock. He could understand what was being said, but he could not speak. He was transported to our department. On arrival, his vital signs were: blood pressure, 86/50 mmHg; pulse rate, regular at 110/minute; saturation of peripheral oxygen in room air, 98%; and tympanic temperature, 36.4°C. Spontaneous hematoemesis was performed for his left wrist cuts. He had no motor weakness or dysesthesia in any of his extremities. He had difficulty opening his mouth and sticking out his tongue. He could write his name slowly using his right hand, but his characters were poorly formed. He was suspected to be in hemorrhagic shock, so he received rapid infusion of 500 ml of Lactate Ringer's solution, and his wounds were closed. His vital signs returned to within the normal range after this treatment, without the need for a transfusion. The abnormal results of his blood biochemical analyses were as follows: white blood cell count, 21900/μl; glucose, 239 mg/ dl; blood urea nitrogen, 25 mg/dl; creatinine, 2.23 mg/dl, and HbA1c was 5.0%. A computed tomography (CT) scan of the head revealed a low density area in the right insular and external putamen. An electrocardiogram and sonography for evaluation of the heart, coronary artery, and carotid artery were negative for any pathological finding. Magnetic resonance imaging (MRI) of the head demonstrated multiple small high intensity areas in the right frontotemporoparietal lobe and left thalamus, in addition to the head CT findings []. A magnetic resonance angiogram showed no stenosis or occlusion of the cerebral arteries. The biochemical analyses of the cerebral spinal fluid were negative. A transcranial Doppler examination did not show any evidence of microemboli, even when using microbubble infusion with the Valsalva Maneuver. The patient subsequently received a diagnosis of speech apraxia, motor aphasia, and dysgraphia due to multiple cerebral infarctions. Olanzapine was changed to Perospirone. His deficits gradually improved, and he could speak again beginning on the fourth hospital day. As his D-dimer level had increased from 1.7 on arrival up to 12 μg/ml on the tenth day, warfarin and aspirin were prescribed. The results of the biochemical analyses of his blood were as follows: Antithrombin III, 105.0%; protein C, 93%; protein S, 79.8%; lupus anticoagulant, 0.8 seconds; anti-nuclear antibodies x 40; anti-cardiolipin IgG antibodies, 8 U/ml; von Willebrand factor, 200% (50 – 150%); X-factor, 94%; myeloperoxidase-anti-neutrophil cytoplasmic antibodies, negative; and cytoplasmic-anti-neutrophil cytoplasmic antibodies, negative. After his mental state was considered to have sufficiently stabilized, he was discharged on the twenty-fifth hospital day.