Wallenberg "Plus" In A Patient With Cold Agglutinin Syndrome: A Case Report.

Case Diagnosis: 45-year-old male with bilateral medullary infarction secondary to cold agglutinin syndrome.

Case Description or Program Description: The patient presented to an outside hospital (OSH) with right hemiparesis following an airplane flight. He required tracheostomy placement secondary to bilateral medullary infarction. He also underwent percutaneous endoscopic gastrostomy (PEG) placement for dysphagia. MRA revealed complete occlusion of the distal left V3/V4 segment and near complete occlusion of the right proximal V4 segment. OSH course was complicated by unreadable hemoglobin values with peripheral blood smear showing pan agglutination of red blood cells suggestive of cold agglutinin disease. Patient was admitted to AIR 45 days after presentation to OSH. His physical exam was remarkable for right eye ptosis, intact strength of left upper and left lower extremities (LUE and LLE, respectively), decreased strength of right upper and right lower extremities (RUE and RLE, respectively), intact sensation to light touch of LUE and LLE, impaired sensation to light touch of RUE and RLE, and dysmetria of LUE.

Setting: Acute Inpatient Rehabilitation (AIR).

Assessment/Results: After 23 days at AIR, patient has advanced from ventilatory support to speaking valve/uncuffed tracheostomy on room air. He remains PEG dependent secondary to paralyzed left vocal fold and reduced mobility of right vocal fold. Right hemiparesis is improving and he is engaging in therapeutic ambulation and performing activities of daily living with minimum to moderate assistance.

Discussion (relevance): Wallenberg Syndrome typically presents with dysphagia, contralateral sensory impairments, and ipsilateral dysmetria. Our patient’s right hemiparesis is consistent with a more extensive lesion than the one that causes a more traditional Wallenberg Syndrome. Perhaps this lesion extended to the pyramidal tracts.

Conclusions: Lesions beyond the lateral medulla should alert the rehabilitation team to the possibility of other signs and symptoms on both contralateral and ipsilateral sides of the stroke. Further studies of such Wallenberg “Plus” Syndromes should be explored.