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Moyamoya’s Syndrome related to pulmonary tuberculosis - case report

RESUMO

Case presentation
Female, 19 years old, admitted to the ER with acute desaturation, and a one month’s history of fever and cough, in use of rivaroxaban for a 3 weeks diagnosis of pulmonary embolism; has shown worsening for a week.
Neurology has been called to evaluate for an acute confusional state, lower limb weakness and respiratory symptoms.
Previously higid, the patient had domiciliary Pulmonary Tuberculosis contact.
To the neurologic examination: sleepness, lentified, disoriented in time and space, no language impairment, mild dysarthria, muscle grade 1 on left and 3 on the right, and heightened deep reflexes.
Previous hospital admission review: Tomography showed ischemic areas in the vascular frontier territory, the new CT has shown new hypoattenuating cortico-subcortical areas in the frontal and parietal high convexities of both hemispheres, determining amplitude reduction of some adjacent liquor spaces. AngioCT has shown no thrombus, but an unspecified narrowing in the internal carotid. Cerebrospinal Fluid: protein elevated (62mg/mL), undetectable Mycobacterium tuberculosis PCR. Angiography: occlusions and “smoke” aspect collateral circulation, suggesting Moyamoya’s disease. Laboratory investigation for thrombophilias, falciform anemia and other infections has turned negative.
One month of treatment, no cough or dyspnea, with progressive improvement of the neurologic symptoms. In 60 days, she was evaluated in the ambulatory, alert, oriented and muscular strength grade 4 to the left, still in rehab. The investigation still awaits anticoagulation cessation for complete neurovascular evaluation.
Discussion
Moyamoya in the terminology that refer to the progressive narrowing of a big intracranial artery in parallel to multiple collaterals that confer the “smoke” to the angiography. It’s called Moyamoya's disease when it has genetic association, and Moyamoya’s Syndrome when related to other clinical entities. A few case reports relate the syndrome to standard resistant tuberculosis treatmen and Neurotuberculosis, cases with long infection periods, necessary to the disease’s progress and collateral circulation development.
Final remarks
Despite the findings of Moyamoya Syndrome and its association with tuberculosis being described in few cases in the literature, it is possible that the chronic infectious condition plays a role in the pathophysiology of the neurovascular condition.

Palavras Chave

Moyamoya Syndrome, Pulmonary Tuberculosis, Ischemic Stroke