Transient Ischemic Attacks in a 22-Year-Old
A frightening symptom in a 22-year-old undergraduate student signaled an uncommon chronic disease—and led to reconsideration of a previous diagnosis. In July 2010, she presented with a 2-month history of a “whooshing sound” in her right ear. She noted the sound when trying to sleep, though it did not interfere with sleeping. She denied tinnitus or headaches. For the previous 7 weeks, she had experienced right-neck tenderness and stiffness, particularly with flexion of the cervical spine. The onset of these symptoms was associated with fever and dysphagia that resolved in 1-2 days without treatment. One week prior to admission, she experienced 6-10 episodes of transient (< 1 minute) loss of vision in the right eye, as well as severe fatigue.
In 2008, the patient had been diagnosed with the intimal variant of fibromuscular dysplasia of the right renal artery, found after an evaluation for malignant hypertension with debilitating headaches. The diagnosis was based on the characteristic focal severe stenosis of the mid-right renal artery without involvement of the aorto-ostial segment in the setting of normal inflammatory markers and no constitutional symptoms. Following endovascular therapy, her blood pressure normalized immediately, requiring no further antihypertensive medications, and her headaches resolved.
In the year prior to her current presentation, the patient had stable exertional right-calf cramping that was relieved with rest. The results of repeated symptom-limited physiologic arterial studies with treadmill testing were normal, as was duplex ultrasonography and magnetic resonance (MR) arteriography of the right lower-extremity arteries. Exertional compartment pressures were elevated, suggesting chronic exertional compartment syndrome.
Her medications included aspirin and clopidogrel. She never smoked tobacco or used illicit drugs. There was no family history of vascular disease.
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— R. Kevin Rogers, MD, MSc, Rahul Sakhuja, MD,MPP,MSc, Ronan Margey, MB BCh, John H. Stone, MD, MPH, Kenneth Rosenfield, MD, Michael R. Jaff, DO
This article originally appeared in the February 2012 issue of the The American Journal of Medicine.
