Brain abscess as the first manifestation of pulmonary arteriovenous malformation: A case report
A 25-year-old male came to our hospital, had complains of headache, nausea, vomiting, and fever from five days ago. The general physical examination was unremarkable and neurological exam was also normal.\nPrimary hematologic and biochemistric laboratory data were unremarkable, except for mild polycythemia. Lumbar puncture (LP) was performed and cerebrospinal fluid (CSF) analysis revealed increased protein and white blood cells (mostly neutrophils), but CSF direct smear and also CSF and blood culture were negative.\nFor more evaluation, brain MRI was performed which showed hyposignal and round lesion (about 3.5 cm) in left occipital lobe in T1w image [], associated with high signal intensity capsule and obvious prelesional edema in T2w image [] and no signal loss in Fluid Attenuated Inversion Recovery sequence [], so brain abscess was the first differential diagnosis for patient.\nThen patient underwent craniotomy and occipital brain abscess was the first impression of surgeon during surgery.\nDirect smear of lesion's samples showed many gram positive cocci which was culture positive and identified as streptococcus viridians, so gram positive abscess was confirmed.\nPatient was not drug abuser and in cardiological consult and echocardiaographic exam, there was not any evidence of endocarditis, so, initial source of brain abscess remained undetermined.\nThree days post operation he suffered from right lower limb pain and swelling; he underwent a Doppler ultrasound exam and deep vein thrombosis of right superficial femoral vein was confirmed, then thoracic multislice CT scan was requested to rule out pulmonary thrombo embolism (PTE) because mild dyspnea of patient.\nPulmonary CT angiography was performed with special PTE protocol by 64 multislice CT, and we found partial filling defects in segmental branches of right lower lobe pulmonary artery which were compatible with segmental PTE [], but we were also surprised to see multiple obvious pulmonary arterio-venous malformations (AVM) as multiple masses or nodular densities with well defined and lobular margin containing feeding artery and draining vein [Figures –].\nAfter detecting multiple AVM, patient was reassessed and while reviewing his history and physical examination, we found history of recurrent epistaxis (with frequency of three to four times a week) and patient informed that episodes of epistaxis are usually after eating hot food stuff. So far, the patient did not yet have the need for nasal packing or blood transformation, conversely he had high hemoglobin (about 15.5) in the day of admission, indicating mild polycythemia. This polycythemia could be due to degrees of hypoxemia secondary to multiple arterivenous shunts, which is similar to other types of right to left shunts.\nAlso, his father and one of his sisters had recurrent epistaxis without any other complications.\nIn repeated physical exam, we noted telangiectatic lesions in his leg and ankle, so, four of four curacao criteria[] for HHT were fulfilled and Osler-Weber- Rendu syndrome was confirmed for the patient. There was no obvious clubbing or cyanosis. Also, abdominopelvic sonographic study was unremarkable and there was no any hepatic, splenic, or pancreatic lesion. Consultation with radiologist for interventional procedures and also with surgeon was requested for patient, but unfortunately patient left hospital on his own request and responsibility and refused further therapeutic options.