A 51-year-old man with multiple myeloma was admitted to the ICU with severe sepsis, 2 months after an unrelated allogeneic stem cell transplant. On the day of planned hospital discharge, he developed tachypnea, diaphoresis, and agitation within 15 to 20 min after removal of a right subclavian central venous catheter (CVC) while lying flat in bed. This episode rapidly progressed to obtundation and cardiopulmonary collapse, necessitating emergency intubation. His ECG showed a new right bundle-branch block (RBBB) (Fig 1). Chest CT was negative for pulmonary embolism. Results of duplex studies of the lower limbs, right side of the neck, and right upper extremity were negative for DVT. Transthoracic echocardiogram performed with agitated saline solution injection demonstrated saline bubbles in the left atrium (Fig 2). Transesophageal echocardiogram revealed a small patent foramen ovale (Fig 3). Head CT showed diffuse global cerebral edema and MRI revealed multiple bilateral cortical and subcortical emboli. Over the ensuing days, his mental status, speech, and motor function improved, and he was extubated on ICU day 5. However, he continued to have motor deficits and required physical rehabilitation.
What is the diagnosis? What are the mechanisms for neurologic deficits in this disorder? How is this condition managed?
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