Case Presentation:
A 30-year-old woman who had given birth two weeks ago was admitted to a
regional hospital due to fever, palpitation, erythema, inflammation and
secretion around the cesarean wound. Her vital signs were: T:37.3
BP:110/70 PR:89. Initial laboratory findings revealed R.B.C: 4.4 ×
106/µL, Hb:11.6 g/dL, Hct: 36%, W.B.C: 11.6 ×103/µL, Plt: 213×103/µL,
Neutrophil: 73%, Lymphocyte: 18%, Monocyte: 5%, Eosinophil: 5%. So
Primary diagnosis set for wound infection. Because of infection Amp
Cefazolin (1 gr IV for 9 doses) and Amp Gentamicin (80 mg IM for 6
doses) and Amp Metronidazole (500 mg IV 7 doses) were ordered. After
five days she complained of hearing loss so Gentamicin was stopped. She
was also ex-addicted and taking methadone during abstain.
At day 9 of admission, she developed neural complications including
nausea, vomiting, aphasia, loss of consciousness, hearing disturbances,
extreme rigidity and gazed eyes so she was referred to Alborz hospital.
There initial laboratory tests were as following: R.B.C: 4.7 × 106/µL,
Hb:13.5 g/dL, Hct: 41.3%, Plt: 213×103/µL, W.B.C: 15.4 ×103/µL
(Neutrophil: 92%, lymphocyte: 8%), AST: 29 IU/L, ALT: 18 IU/L, Sodium:
136 mEq\L, Potassium: 4.4 mEq/L, CRP: 33, PH:7.307, PCO2:
26.9, HCO3: 13.2, PO2: 185.8, SO2: %99.2, Urea 28, Cr: 1
mg\dL. There were evidences proving inflammation
existence, So HBsAg, HCVAb, HIVab and blood culture was set which all
were negative. Iso Electric Focusing for CSF & Serum was done and OCB
was negative. CSF culture, fluid examination and oligo clonal banding
test didn’t show any abnormality (Table1,2,3).
Brain MRI performed in axial T1, T2, FLAIR, DW and sagittal and coronal
T2 sequences to examine brain functions in which diffuse white matter T2
increased signal changes were seen in periventricular regions on both
sides and also in the corpus callosum. That showed restriction on DWI
images. (figure 1). These findings are non-specific and could be due to
inflammatory-infective causes as ADEM, HIV, PRES or vascular causes as
CADASIL, so it was referred to molecular detection section for CSF
pathogen panel. CSF viral pathogen panel showed negative for EBV, CMV,
HSV1, HSV2, VZV, HHV 6, HHV7, Parvovirus B19, Human enterovirus.
At the entrance to Alborz hospital (9 days after first admission), she
was hospitalized in ICU and took Methylprednisolone 1gr/day for 5 days,
which was not effective, after that Plasmapheresis was done for 7 times
by the amount of 2-2.5 liters with the substitution of FFP and Albumin
which was again ineffective. She was ordered to 130 gr IVIG infused in
divided doses in 5 days. After the patient was stable, she was ordered
to MRI again in which Mild dilation of ventricle along with widening of
lateral sulcus was noted. Cerebellar hemispheres vermis and dentate
nucleus was visualized normally. Pathologic signal is not demonstrated
in pons and medulla oblongata. Craniocervical junction appears normal.
Extra or intra-axial collection in dura and meninges was not seen.
signal void was seen normally in major arteries. Pathologic signal was
not visualized in intracranial veins. There was not any space occupying
lesion in basal cisterns. visualized parts of orbit had normal
configuration. Macroadenoma was not seen in hypophysis. Stalk was
normal. Suprasellar cistern was free. In DWI images, diffusion
restriction and acute infarction was not seen Severe mucosal thickening
was noted at ethmoid complex and also sphenoid sinus and less than
severely at mastoid air cells (figure 2). At last, after 52 days she
could talk and move voluntarily and ordered to take Depakine, Metoral,
Plazil, Gemfibrozil, and Quetiapine.