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This 39-year-old woman
was admitted because of weakness and numbness over right extremities
since March 4, 2000.
She was quite
well until March 3 when she began to suffer from
flu-like symptoms including general malaise, rhinorrhea and headache.When she
was awakened in the next morning, she began to notice numbness and
weakness over right upper and lower extremities that
she could not climb stairs or comb her
hair well. She visited Emergency Room of National Taiwan University Hospital where
no fever, dysarthria, diplopia, slurred speech, facial palsy
or sphincter incontinence was noted. There was no ear pain, chronic
rhinorrhea or trauma history. Mild dragging of right leg, mild
proximal muscle weakness and mildly increased deep tendon reflex
were noted on neurological examinations. She was admitted on March
8.
On admission, the blood pressure
was 120/70 mmHg, pulse rate 82/ min respiratory rate 20/min
and body temperature 37.2oC. The body height was 149 cm and
weight 49 kg. The head and neck were grossly normal.
Mild capillary
engorgement
was found over the conjunctiva and
lower lip. There were no goiter, jugular vein engorgement or
lymphadenopathy over the neck. The breathing sound was clear
and the heart rate was regular without thrill, heave or
murmur. The abdomen was soft and flat with normoactive bowel
sound. There were normal axillary and pubic hairs. The
extremities were freely movable except mild proximal muscle
weakness without sensory deficits .
Tracing back her history,
there was no hypertension, diabetes mellitus or other systemic
diseases. There was a family history of unknown cause of
frequent epistaxis and so does she. She doesn't smoke or drink
alcohol. Laboratory results:
CBC
| |
WBC
(K/ul) |
RBC
(M/ul) |
Hb
(g/dl) |
Hct
(%) |
MCV
(fl) |
MCHC
(g/dl) |
Plat
(K/ul) |
Seg
(%) |
Eos
(%) |
Baso
(%) |
Mon
(%) |
lym
(%) |
| Mar 4 |
10.8 |
4.59 |
15.0 |
42.9 |
93.5 |
35.0 |
188 |
77.9 |
0.2 |
0.2 |
4.3 |
17.4 |
Biochemistry
| |
AST |
ALT |
Albumin |
Globulin |
ALP |
Glucose |
Bilirubin(T) |
BUN |
Cr |
UA |
| |
U/L |
U/L |
g/dl |
g/dl |
U/L |
mg/dl |
mg/dl |
g/dl |
mg/dl |
mg/dl |
| Mar 9 |
19 |
33 |
3.9 |
3.4 |
96 |
95 |
0.6 |
13.3 |
0.9 |
6.3 |
| |
T-CHO |
Na |
K |
Ca |
Cl |
P |
| |
mg/dl |
mM |
mM |
mM |
mM |
mg/dl |
| Mar 9 |
203 |
142 |
4.0 |
2.39 |
101 |
3.6 |
VDRL: Negative
U/A, Stool: within normal limit
Blood culture: no growth
Coagulation: PT 12.2/11.5, PTT 31.6/31.1
Course and Treatment :
Head
CT showed a
nodular lesion at left high frontoparietal lobe with
obvious perifocal edema but no intracranial hemorrhage. MRI showed
a space-occupying lesion with perifocal edema and ring-enhancing picture
suggesting a brain abscess . Decadron was administered since Mar
10. The numbness and weakness improved gradually. She received craniotomy on
Mar 16 for abscess drainage and irrigation. Yellowish discharge from
left parietal lobe was smoothly drained under ultrasound guidance. Focal seizure and twitching
over right arm without unconsciousness ensued in that night,
which were relieved spontaneously after a
few minutes. Unasyn (Ampicillin/Sulbactam) and Gentamicin were administered since after
operation. the abscess culture yielded Actinomyces
meyeri . Penicillin G 1,800 MU/day was given since Mar 27,
when the pathology of the tissue was abscess only without
visible pathogen. A metastatic lesion or pulmonary tumor
was suspected over the left lower lung field on a chest roentgenogram on Mar 16, which
was previously described as suspective lymphadenopathy on
Mar 8. Chest
CT was performed on Mar 20. The
impression of that lesion was pulmonary AV fistulae. One episode
of epistaxis ensued on Mar 23 . No abnormal
vessel engorgement except nyperemic mucosa was found. Pulmonary angiography was performed on
Apr 6 and confirmed the diagnosis of pulmonary AV
malformation. Spiral CT
further documented multiple AVM and may provide a tool for
follow-up. Trans-esophageal echocardiography on Apr 7 showed no ASD, no
vegetation over all valves and good LV contractility. Duplex
abdominal echo showed prominent hepatic arterial and normal hepatic
venous flow with a vascular malformation over distal
branch of vessel. She received parenteral antibiotics for 6 weeks and followed
by oral antibiotics.
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Case Discussion
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