Case Presentation: A 37-year-old man with type 2 diabetes mellitus presented with an episode of bifrontal and retro-orbital headache, left-sided upper extremity and facial numbness, generalized weakness, and dysarthria. The patient reported similar symptoms one week prior to presentation that lasted 12 hours, and which were accompanied by syncope. Over the past month, the patient reported a 10-pound unintentional weight loss, lower extremity numbness, shortness of breath, and subjective fevers. The patient reported no tobacco use.Vital signs were within normal limits. Physical exam was notable for diminished sensation to light touch and pinprick in the left upper extremity, right upper extremity drift without pronation, and gait instability. Lungs were clear to auscultation.Labs were significant for a slight leukocytosis of 12.53 and a lactate of 2.2. CT of the head and neck demonstrated multiple enlarged cervical chain lymph nodes as well as a partially visualized chest mass effacing the left pulmonary arteries; there was no evidence of stroke or intracranial hemorrhage. CT chest revealed a well-circumscribed, highly vascularized soft tissue mass in the mid-left thorax abutting the mediastinum. The left segmental pulmonary arterial branches and bronchi appeared to course through the mass. CT-guided core biopsies and FNA of the mass demonstrated a high-grade cellular spindle cell neoplasm infiltrating the lung parenchyma. Further immunostaining confirmed a diagnosis of monophasic synovial sarcoma.The patient was discharged home and underwent surgical resection of the mass three months later.
Discussion: Numbness and weakness are complaints commonly encountered by the hospitalist. Extracranial pathologies must be considered when these symptoms are diffuse. In our patient who exhibited transient non-focal deficits, cerebral hypoperfusion remained high on the differential. Cerebral blood flow insufficiency has a multitude of etiologies ranging from vasculitis to arrhythmias. Patients experiencing vertebrobasilar hypoperfusion can present with headache, fatigue, numbness, dysarthria, syncope, and unilateral numbness of face, hand, and foot. In our patient, cerebral hypoperfusion was a result of a pseudo-subclavian steal syndrome due to the immensity of blood flowing through the dysregulated tumor vessels. Synovial sarcomas are hyper-vascular and can cause displacement of native vessels. They are uncommon malignancies affecting about one to two in a million people every year. While they are usually found in the arms, legs, and near joints, synovial sarcomas can rarely develop in the lung and abdomen. Arteriovenous shunting occurs in about 24% of people with synovial sarcomas and can cause starvation of oxygen to nearby areas.
Conclusions: Cerebral blood flow insufficiency typically presents with diffuse neurologic complaints. Synovial sarcomas of the lungs are hyper-vascular and can result in a pseudo-subclavian steal syndrome.