Polak P, Snopkova S, Husa P
Klinik für Infektionskrankheiten, Universitätskrankenhaus und Medizinfakultät, Masaryk-Universität, Brno, Tschechien.
Dtsch Med Wochenschr. 2012 Aug;137(33):1635-8. doi: 10.1055/s-0032-1305184. Epub 2012 Aug 8.
A 38-year-old woman who suffered from migraine was admitted because of severe, worsening headache for 24 hours (dissimilar to the previous migraine attacks), with impaired vision and weakness of the right arm. Mild hemiparesis and expressive aphasia indicated an intracranial tumor.
Cranial computed tomography revealed a focal lesion with a diameter of 2.5 cm in the left frontoparietal lobe, with signs of intracranial hypertension, indicating cerebral metastasis or an abscess. Magnetic resonance imaging confirmed the diagnosis of a brain abscess.
An urgent craniotomy was performed and the abscess was evacuated. An empirical antibiotic combination with chloramphenicole and metronidazole (switched to cefotaxime because of thrombocytopenia) was initiated. Cultivation of pus revealed Streptococcus constellatus, Aggregatibacter aphrophilus and Fusobacterium spp. Within the first two weeks of treatment progession of the abscess was noted, therefore a second craniotomy with debridement was performed. An elective CT-angio scan revealed several arteriovenous malformations in the caudal segments of both lungs which were embolized without complications. Only retrospectively, cutaneous teleangiectasias were recognized. At present, the patient and her direct relatives are submitted to genetical screening for Osler's disease.
In patients with brain abscesses of unknown origin and with a history of repeated epistaxis and/or gastrointestinal bleeding, Osler's disease (hereditary hemorrhagic telangiectasia) should be considered and pulmonary arteriovenous malformations excluded. Physicians should search for cutaneous or mucous teleangiectasias. Family screening and long-term follow-up according to international guidelines is recommended.
一名38岁患有偏头痛的女性因严重且逐渐加重的头痛（与既往偏头痛发作不同）持续24小时，伴有视力障碍和右臂无力而入院。轻度偏瘫和表达性失语提示颅内肿瘤。
头颅计算机断层扫描显示左额顶叶有一个直径2.5厘米的局灶性病变，伴有颅内高压迹象，提示脑转移瘤或脓肿。磁共振成像确诊为脑脓肿。
紧急进行了开颅手术并引流脓肿。开始经验性使用氯霉素和甲硝唑联合抗生素治疗（因血小板减少改为头孢噻肟）。脓液培养显示有星座链球菌、嗜沫聚集杆菌和梭杆菌属。在治疗的前两周内发现脓肿进展，因此进行了第二次开颅清创手术。选择性CT血管造影扫描显示双肺尾段有几处动静脉畸形，已进行栓塞且无并发症。只是在回顾时才发现皮肤毛细血管扩张。目前，患者及其直系亲属正在接受遗传性出血性毛细血管扩张症（Osler病）的基因筛查。
对于病因不明且有反复鼻出血和/或胃肠道出血病史的脑脓肿患者，应考虑遗传性出血性毛细血管扩张症（Osler病）并排除肺动静脉畸形。医生应查找皮肤或黏膜毛细血管扩张。建议根据国际指南进行家族筛查和长期随访。
