title: Multiple hemorrhagic strokes from DIC associated with occult large cell carcinoma.
abstract: OBJECTIVE
  Multiple hemorrhagic strokes are a rare presentation of paraneoplastic disseminated intravascular coagulation (DIC). We present a case of DIC occurring in a patient with occult large cell carcinoma.
  
  
  METHODS
  A 77-year old Asian-American man presented with 1 month of vision disturbance followed by acute onset of left hemiparesis and encephalopathy. He was found to have three strokes of varying ages, and was placed on aspirin and clopidogrel. He returned 4 days later with hemorrhagic conversion of the strokes and laboratory abnormalities suggestive of DIC. Over the hospital course, he suffered recurrent ischemic strokes and intracerebral hemorrhages despite management of his coagulopathy. On autopsy, an occult large cell carcinoma was found in the hilar lymph nodes, as well as multiple intravascular thrombi.
  
  
  CONCLUSIONS
  Recurrent hemorrhagic strokes associated with DIC may be the initial presentation of occult malignancy. Although adenocarcinoma is classically associated with paraneoplastic DIC, this case demonstrates that large cell carcinoma may also be implicated.
authors.affiliation: Division of Neurosciences Critical Care, Johns Hopkins Hospital, Baltimore, MD, USA. mkoenin1@jhmi.edu
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Koenig
authors.forename: Joseph
authors.initials: J
authors.lastname: Maleszewski
authors.forename: Brad
authors.initials: B
authors.lastname: Winters
mesh_terms: D000368:Aged; D018287:Carcinoma, Large Cell / Q000473:pathology*; D002543:Cerebral Hemorrhage / Q000473:pathology*; D002544:Cerebral Infarction / Q000473:pathology*; D003937:Diagnosis, Differential; D004211:Disseminated Intravascular Coagulation / Q000473:pathology*; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism; D006801:Humans; D019934:International Normalized Ratio; D008168:Lung / Q000473:pathology; D008175:Lung Neoplasms / Q000473:pathology; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D009382:Neoplasms, Unknown Primary / Q000473:pathology*; D020361:Paraneoplastic Syndromes, Nervous System / Q000473:pathology*
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D