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Título

CASE REPORT: ENCEPHALOMYELORRADICULITIS OF UNKNOWN ETIOLOGY IN A YOUNG PATIENT

RESUMO

Case Report: 49 year old male patient with controlled hypertension was hospitalized with a first-time seizure. Three months before hospitalization he presented a persistent low back pain which progressed to an intermittent left hemiparesis. Those symptoms were previously assigned to a C4-C5 disc herniation. Magnetic resonance imaging showed an irregular lesion in the right temporal lobe causing mass effect in addition to an extensive cervicothoracic myelopathy with contrast enhancement and a diffuse leptomeningitis affecting even cauda equina roots. The cerebrospinal fluid (CSF) sample had 50 cells/microL, with a lymphocytic predominance, 663 mg/dL proteins and glucose consumption. Oncocytic cells and the antineuronal antibody panel were negative. Adenosine deaminase (ADA) at CSF was 1 U/L, not suggestive of tuberculous meningitis. Oligoclonal bands were present in both CSF and serum suggestive of a systemic inflammatory process. The CSF immunohistochemistry and rheumatologic/infectious workup were negative. Angiotensin-converting enzyme (ACE), anti-myelin oligodendrocyte glycoprotein (MOG) and anti-aquaporin-4 (AQP4) were non-reactive. Chest and abdomen tomographies showed no neoplasms. Biopsy of the temporal lesion resulted in nonspecific meningoencephalitis, with no signs of malignancy. The CSF metagenomic sample is still without a definitive result. Patient was referred for a external ventricular drain implantation for intracranial pressure monitoring. In addition, empirical plasma exchange was started. However, it was not possible to observe the patient’s response since he progressed with a septic shock due a Staphylococcus haemolyticus bloodstream infection. By the sixth day after admission brain death was certified. Discussion: This case report presented itself as a challenging clinical case in a previously functional young patient with multiple active central nervous system lesions. Considering the main hypotesis, inflammatory disease and neoplasm, several procedures were performed, especially MOG, anti-neuronal antibody panel, CSF immunohistochemistry and metagenomic sample. Some of these exams are still not easily available in medical practice and may be extremelly important for some etiological diagnosis. Final Comments: Neurological cases without etiological definition occur occasionally in medical practice. Therefore, it is important for neurologists to share experiences for the establishment of new approaches in daily practice.

Palavras Chave

ENCEPHALOMYELORRADICULITIS