Cerebral microbleeds in a young patient – case presentation with rare disease association and literature review

Máté Tihamér, Mihály István, Kelemen Krisztina, Szász József Attila, Szatmári Szabolcs
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Abstract

Abstract During the coronavirus pandemic neurology departments were forced to treat diseases that had hitherto been treated by other specialities. In our case presentation, we describe an unusual association of two diseases that raised interesting questions regarding differential diagnostics and has not yet been presented in the literature. A 34-year-old male patient was admitted to the neurology department with an urgent referral because of impaired speech comprehension and expression upon awakening. He had a history of anticoagulant therapy for thrombosis of the posterior tibial artery, discontinued after two weeks. Physical examination revealed a 1 cm diameter painful lump in the subcutis of his right thigh and a systolic murmur over the mitral and aortic valves. Nonenhanced head CT showed a small hemorrhage near the occipital horn of the left ventricle, which could not explain the mixed aphasia. In addition, the SWAN MRI sequence showed supra- and infratentorial microbleeds, suggesting cavernomatosis, which was confirmed by the detection of another typical popcorn-like bleeding cavernoma on repeated MRI examination. Due to the heart murmurs and positive inflammatory markers, a detailed cardiac examination was warranted, confirming infective endocarditis caused by Streptococcus gordonii. Due to COVID-19-related regulations the patient couldn’t be transferred to the Department of Cardiology or Infectious Diseases, thus his treatment and follow-up was carried out at the Department of Neurology. Following targeted antibiotic treatment the patient’s symptoms resolved and he underwent successful cardiac surgery 7 weeks after his discharge in a symptom-free state. The peculiarity of the case lies in the fact that the clinical picture and course of the disease, consistent with the diagnosis of infective endocarditis suggested cerebral septic emboli with microbleeds, but cerebral cavernomatosis was confirmed by brain imaging.
年轻患者脑微出血1例与罕见病的关联及文献复习
在新型冠状病毒大流行期间,神经科被迫接受其他专科治疗的疾病。在我们的病例介绍中,我们描述了两种疾病的不寻常关联,这些疾病提出了关于鉴别诊断的有趣问题,并且尚未在文献中提出。一名34岁男性患者因醒后言语理解及表达障碍而被紧急转诊至神经科。患者曾因胫骨后动脉血栓而接受抗凝治疗,两周后停用。体格检查发现他的右大腿皮下有一个直径1厘米的疼痛肿块,二尖瓣和主动脉瓣有收缩期杂音。头部非增强CT显示左心室枕骨角附近小出血,不能解释混合性失语。此外,SWAN MRI序列显示幕上及幕下微出血,提示海绵瘤病,反复MRI检查发现另一例典型的爆米花样出血海绵瘤。由于心脏杂音和阳性炎症标志物,需要进行详细的心脏检查,确认由戈多氏链球菌引起的感染性心内膜炎。由于新冠肺炎相关规定,患者无法转至心内科或感染性疾病科,因此在神经内科进行治疗和随访。经过靶向抗生素治疗,患者症状消失,出院7周后,患者在无症状状态下成功进行了心脏手术。本病例的特殊之处在于临床表现和病程与感染性心内膜炎的诊断一致,提示为脑脓毒性栓塞伴微出血,但脑影像学证实为脑海绵瘤病。
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