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.