commentary case 3

A pregnant woman with headache and

visual symptomsBy :

Prof. Dr. : Fawzy MegahedAss. Lec. : Mahmoud Negm

A 30-year-old pregnant woman (gravida 2, para 0) was admitted to this hospital at 33 weeks of gestation because of headache and visual symptoms.

The patient had been in her usual health until 2 weeks before admission, when neck

pain developed.

Eleven days before admission, she was seen in the emergency department because of neck and back pain, occipital headache,

vomiting .

On examination, the back was tender; the vital signs and remainder of the examination

were normal.

Urinalysis revealed yellow, cloudy urine, with trace ketones, 1+ albumin, and 2+

urobilinogen .

Paracetamol was prescribed, with some improvement. The patient was discharged home.

The headache improved spontaneously after 3 days.

At the time of presentation

The patient felt the onset of a panic attack followed by tunnel vision; she began to hyperventilate and her vision went black from the periphery to

the center.

The symptoms lasted for approximately 2 minutes and were followed by spots in her visual fields, headache, neck pain that radiated to her arms, nausea, and dizziness .

The patient reported normal fetal movement and no fever, diarrhea, abdominal pain, vaginal bleeding, leaking fluid, or

contractions.

During the third trimester, a glucose-tolerance test was positive. She had intermittent atypical chest pain that had lasted for several years .

2.5 months before admission, an evaluation of the pain was done including ECG, which revealed non specific ST-segment and T-wave changes, and transthoracic echocardiography , which was

normal.

3 years ago , she had presented at 20 weeks of gestation with sepsis and a stillborn fetus; dilation and evacuation had

been performed.

She also has anemia (with a history of iron deficiency), asthma , and seasonal allergic rhinitis .

She had undergone multiple laparoscopies , including cholecystectomy for cholelithiasis, lysis of adhesions , and ovarian

cystectomies.

Medications included a prenatal multivitamin and ferrous sulfate.

She did not smoke, drink alcohol, or use illicit drugs.

Her mother had had breast cancer and died in her 50s.

To summarize the case

A 30 year old female presented in her 3rd trimester by headache , neck pain , nausea , vomiting and a panic

attack . She also has a histoey of anemia ,

atypical chest pain , asthma and allergic rhinitis .

Her previous pregnancy ended at 20th week by sepsis and stillborn fetus.

On examination

The temperature was 36.7°C, the blood pressure 117/68 mm Hg, the pulse 104 beats per minute, and the respiratory rate 18

breaths per minute.

Her abdomen was gravid, soft, and nontender, with active fetal movements. The fetal heart rate tracing was

reassuring.

There was no peripheral edema or abdominal tenderness. Reflexes were normal, as were the remaining general and neurologic examinations.

The blood glucose level was 111 mg per deciliter . Blood levels of uric acid, magnesium, calcium, phosphorus, total protein, globulin, and total and direct bilirubin were

normal.

The other test results are shown in the following

table .

Intravenous fluids and acetaminophen–caffeine were administered, followed by prochlorperazine , and diphenhydramine; the patient’s condition partially improved.

Magnetic resonance imaging (MRI) of the head could not be performed because of the

patient’s anxiety.

After 24 hours, the patient’s symptoms had not resolved, and She reported severe occipital

headache .

Later that day, MRI of the head was performed without the administration of contrast

material .

The lesions were thought to reflect infarcts that had occurred at least 6 hours

earlier. A 48 hour follow up MRI was

done .

Results of magnetic resonance angiography and venography were normal. Ultrasonography of the legs revealed no evidence of DVT .

To summarize the case

A 30 year old female presented in her 3rd trimester by headache , neck pain , nausea , vomiting and a panic

attack . She also has a histoey of anemia ,

atypical chest pain , asthma and allergic rhinitis .

Her previous pregnancy ended at 20th week by sepsis and stillborn fetus.

MRI is suggestive of multiple strokes. Laboratory work up revealed

abnormal CBC , dyslipidemia , abnormal levels of naturally occuring anicoagulant protiens , gestational diabetes and high CRP.

What is your differential diagnosis?

• Eclampsia with hypertensive encephalopathy• Ischemic strokes due to hypercoaguablity• Cardioembolism• Drug abuse• Viral encephalitis• Cerebral vasculitis• Other diagnosis ????

What is your next step ?

ECG showed sinus tachycardia at a rate of 108 beats per minute and nonspecific ST-segment and T-wave changes.

Holter monitoring did not reveal an arrhythmia. A lumbar puncture was unsuccessful. Aspirin (81 mg daily), metoclopramide, and prenatal vitamins were administered.

On the third day

The PT , INR , and aPTT were normal, as were results of tests for factor VIII, partial-thromboplastin time – lupus anticoagulant, anticardiolipin

IgG and IgM antibodies.

Results of tests for functional antithrombin III, functional protein C, activated protein C resistance, and prothrombin gene mutation were normal .

Betamethasone was administered to promote fetal lung maturity. An active, well-grown fetus was seen on ultrasound examination. The patient’s headache resolved.

The next day ……

On evaluation by ophthalmology consultants, she reported no acute change in vision, eye pain, or eye redness, but she did have floaters, which she described as

“worms “.

On examination, there was binocular horizontal diplopia (which could be relieved with the use of corrective lenses) and

a pterygium on the left side .

No evidence of papilledema, embolic phenomena, or vasculitis on funduscopic

examination.

Testing revealed antibodies to hepatitis A virus; screening for hepatitis B and C viruses was

negative.

What to do next ?????

On the fifth day, transthoracic echocardiography revealed a hyperkinetic left ventricle without wall-motion abnormalities and with obliteration of the left ventricular

cavity during systole.

The right ventricular apex was akinetic and aneurysmal.

In both ventricles, there was prominent accumulation of sessile, smooth-bordered endocardial material with an echodensity that was distinctly different from that of

the myocardium .

Thus, the findings were suggestive of endocardial

deposits.

Tissue Doppler echocardiography, Doppler assessment of the transmitral flow velocity and pulmonary-vein flow velocity revealed that the left ventricular diastolic function was

normal.

These echocardiographic findings are consistent with …………..

LOFFLER’s ENDOCARDITIS

Let us revise our differential diagnosis

• Hypereosinophilic syndrome• Parasitic infection• Churg–Strauss eosinophilic vasculitis• Chronic myelogenous leukemia• Mastocytosis with peripheral eosinophilia• Eosinophilia – myalgia syndrome• Hodgkin disease• Familial eosinophilia

A continuous intravenous infusion of heparin was initiated.

What to do next ?????

Examination of the bone marrow–biopsy specimen revealed normal cellularity and maturing trilineage

hematopoiesis .

No iron was present on an iron stain.

Results of conventional karyotype analysis, fluorescence in situ hybridization for the FIP1L1-PDGRFA, B-cell and T-cell clonality testing by means of PCR assay for an occult lymphoma, and quantitative BCR-ABL testing for

CML were all normal.

What is your next step ?

A stool examination for ova and parasites was

negative .

ELISAs for antibodies against schistosoma sp. , ascaris lumbercoides ,entrobius vermicularis , trichinella and toxocara species were negative .

ELISAs for antibodies against Strongyloides stercoralis was positive .

Diagnosis ??????

Embolic strokes due to Loffler’s endocarditis, which was most likely caused by helminthic infection ( strongyloidiasis) , with secondary hypereosinophilic

syndrome.

Eosinophilia Definition :"Persistent" eosinophilia is blood eosinophilia on 2 occasions, at least one month apart .Blood eosinophil count 1500 cells/mm3 is classically considered the level above which organ damage is more likely to occurNote that tissue eosinophilia with potential for organ damage may be present with a normal blood eosinophil count, and vice versa.

Classification Blood absolute eosinophil count (/mm3)

<500( often <5% of leukocytes)

Normal healthy patient

>500 Eosinophilia

>1500 Hypereosinophilia

>5000 Severe (or Massive)

Management of the case

Initially, delivery was deferred to avoid a preterm birth and to allow time for treatment to improve the patient’s cardiac and neurologic function and reduce the clot

burden in the left ventricle.

• In this case, the reasons to administer glucocorticoids, include maturation of the fetal lungs and the hypereosinophilic

syndrome . • Insulin was administered to maintain

euglycemia.

A cesarean delivery was performed in the main operating room with the patient receiving an epidural anesthetic. A viable male infant was delivered, with a weight of 2960 g and Apgar scores of 7 and 8 at 1 and 5

minutes, respectively.

Albendazole and ivermectin are pregnancy category C drugs . Albendazole was administered only after the baby was delivered. We thought that the administration of ivermectin could not wait until after delivery because of the potential

risk of disseminated strongyloides.

She was discharged on the 14th hospital day; she took a planned 3-week course of albendazole and a tapering course of glucocorticoids. Warfarin was given for 6 months, and oral and parenteral iron were administered for iron deficiency anemia.

The eosinophilia had resolved by the time of discharge and did not recur. The echocardiographic abnormalities had resolved almost completely within 6 weeks after discharge, and more than 3 years later, the patient remains well. Her child is healthy.

Thank you