PMC3064863_01
Head MRI on admission (a-c) and control head CT scan after symptom progression on day 4 (d). a An axial FLAIR image showing an acute infarct in the right putamen (arrow). b A diffusion-weighted image demonstrating restricted diffusion of the lesion, consistent with an infarct. c A small haemorrhage (black dot) is noted within the infarcted area in a T2*-weighted image. d Progression of the haemorrhagic transformation in the putamen on day 4 in CT.
crn0003-0032-f01.jpg
PMC3064863_01_crn0003-0032-f01.jpg
F1
The next day, a head MRI and MR angiography (MRA) revealed a fresh minor infarction at the corona radiata on a FLAIR sequence (fig. 1a), with a diffusion-weighted image showing restricted diffusion of the lesion, consistent with an infarct (fig. 1b), as well as a 3-mm hemosiderin ring at the right putamen (fig. 1c). The head CT scan showed an expansive right-sided intracerebral haemorrhage in the basal ganglia extending to the corona radiata (fig. 1d).
Blood eosinophil count (E9/l) and CRP level (mg/l) in relation to the treatments.
crn0003-0032-f02.jpg
PMC3064863_01_crn0003-0032-f02.jpg
F2
An infectious diseases specialist was consulted, and further diagnostic work-up showed a remarkable blood eosinophilia of 4.89-9.8 E9/l (30-42%) (fig. 2), positive anti-neutrophilic cytoplasmic antibodies (P-ANCA) antibody titer (200; reference value <20), a high serum myeloperoxidase antibody level (63.4 IU/ml; reference value <6) and slightly positive serum proteinase 3 antibodies (9.9 IU/ml; reference value <4), slightly decreased levels of serum IgA (0.74 g/l; reference value 0.88-4.84), normal IgG, but elevated IgG4 (4.45 g/l; reference value 0.08-1.4) (table 1). The blood eosinophils and ANCA antibodies were undetectable 3 days and 1 month after treatment onset, respectively (fig. 2). At that time, he was started on immunoglobulins (0.4 g/kg i.v.) given every 3 weeks as an additive immunomodulatory treatment together with oral corticosteroids (fig. 2).