Transcript A pregnant woman with headache and visual symptoms

A pregnant woman
with headache and
visual symptoms
By :
Prof. Dr. : Fawzy Megahed
Ass. 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 Twave 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?
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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 STsegment 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
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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, Bcell 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 occur
Note that tissue eosinophilia with potential for
organ damage may be present with a normal
blood eosinophil count, and vice versa.
Classification
Eosinophilia
Blood absolute eosinophil
count (/mm3)
<500 (often <5% of
leukocytes)
> 500
Hypereosinophilia
> 1500
Severe (or Massive)
> 5000
Normal healthy patient
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