Delgado S, Durán M I
Servicio de Nefrología, Hospital de Cruces, Baracaldo, Vizcaya.
Nefrologia. 2004;24 Suppl 3:21-5.
The patient was a 55 year-old-woman with chronic renal failure due to idiopathic mesngial deposition of Ig A. She received a second allograft of a kidney from a cadaver. Results of a preoperative serologic Ig G tests for EBV and CMV were positive. She was given triple-drug immunosuppressive therapy, consisting of cyclosporine,azathioprine, and steroids. Seven years later, azathioprine was changed to mycophenolate mofetil. One year later, she was admitted to the hospital with a three to four week history of vertigo (which did not improve after sulpiride was administrated) and an influenza-like syndrome. A CT scan of the brain appeared normal, so paroxysmal positional vertigo was the diagnosis. Two weeks after admission to the hospital, the patient reported visual hallucinations and impairment of consciousness. Results of laboratory tests were leukocyte increase (polymorphonuclear leukocytes), anemia, hyponatremia and renal failure. Chest radiography, brain CT, and electroencephalography revealed no pathologic signs. The CSF examination revealed 300 cells/ml (79% PMNL), glucose 63 mg/dl, protein 45 mg/dl. Six hours later the treatment was initiated with ampicillin, ceftriaxone and ganciclovir iv, she experienced seizures that affected the left side of her body, but without interictal recovery. The patient required intubation and mechanical ventilation in the intensive care unit. An MRI of the brain images, revealed high signal-intensity regions indicating lesions on the bulb, protuberance, mesencephalon, left thalamus and parenchyma adjacent to the corpus callosum (fig. 1). Six days later, the patient partially recovered consciousness, and she had not neurologic sequelae. Intubation was terminated. As soon as PCR revealed EBV DNA in CSF samples, the treatment with ceftriaxone and ampicillin was discontinued. Treatment with ganciclovir was maintained for 8 weeks (4 weeks with iv and another 4 weeks with oral treatment). On day 35, the examination of a specimen of CSF revealed: glucose 46, protein 78, 15 cells/ml (100% lymphocytes). The patient went home on day 55 after admission to our hospital. She regained her normal neurologic function. Three weeks later MRI, showed reduction of the size of the lesions and the lesions on the brain stem had disappeared.
患者为一名55岁女性，因特发性IgA系膜沉积导致慢性肾衰竭。她接受了来自尸体的第二次同种异体肾移植。术前针对EBV和CMV的血清学IgG检测结果呈阳性。她接受了三联药物免疫抑制治疗，包括环孢素、硫唑嘌呤和类固醇。7年后，硫唑嘌呤换成了霉酚酸酯。1年后，她因有3至4周的眩晕病史（服用舒必利后未改善）和类流感综合征入院。脑部CT扫描显示正常，因此诊断为阵发性位置性眩晕。入院两周后，患者报告出现视幻觉和意识障碍。实验室检查结果为白细胞增多（多形核白细胞）、贫血、低钠血症和肾衰竭。胸部X线、脑部CT和脑电图均未显示病理征象。脑脊液检查显示每毫升有300个细胞（79%为中性多形核白细胞），葡萄糖63毫克/分升，蛋白质45毫克/分升。6小时后开始静脉注射氨苄西林、头孢曲松和更昔洛韦进行治疗，她出现了影响身体左侧的癫痫发作，但发作间期未恢复。患者在重症监护病房需要插管和机械通气。脑部MRI图像显示高信号强度区域，表明延髓、脑桥、中脑、左侧丘脑以及胼胝体相邻实质有病变（图1）。6天后，患者部分恢复意识，且无神经后遗症。插管终止。一旦PCR检测显示脑脊液样本中有EBV DNA，头孢曲松和氨苄西林的治疗即停止。更昔洛韦治疗持续8周（4周静脉注射，另外4周口服）。在第35天，脑脊液标本检查显示：葡萄糖46，蛋白质78，每毫升15个细胞（100%为淋巴细胞）。患者在入院55天后出院。她恢复了正常神经功能。3周后的MRI显示病变大小减小，脑干病变已消失。
