Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) complicated by pulmonary arteriovenous fistula and brain abscess

Brain Abscess as a Complication of Hereditary Hemorrhagic Telangiectasia: A Case Report

An 18-year-old male, previously diagnosed with hereditary hemorrhagic telangiectasia (HHT), presented to the outpatient department with a complaint of generalized seizures and fever for the past five days. He had a history of recurrent epistaxis, progressive shortness of breath, and cyanosis. Magnetic resonance imaging (MRI) of the brain revealed an abscess in the temporoparietal region. A computed angiogram of the pulmonary vasculature showed the presence of arteriovenous malformation (AVM). A four-weekly antibiotic regimen was initiated, which resulted in a profound improvement in symptoms. A brain abscess can arise as a complication of vascular malformation in a patient with HHT, providing a nidus for bacteria to migrate toward the brain. Early recognition of HHT is essential in these patients and their affected family members, as screening can help us prevent complications at an earlier stage.

Brain abscess and hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder that can lead to serious central nervous system complications including hemorrhage, ischemia, and infection. Symptoms can be mild, making diagnosis problematic. Fifty-three prior cases of HHT and brain abscess are described, in addition to two new cases. The clinical manifestations and current methods for diagnosis and management of patients with HHT are reviewed. Early recognition of HHT is important because screening in these patients and affected family members may help prevent complications. In addition, advancements in imaging, surgical techniques, antibiotics, and genetic testing may improve outcomes.

Brain abscess in patients with hereditary hemorrhagic telangiectasia: case report and literature review

Hereditary hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu disease, affects multiple organ systems. Brain abscess is a potential complication, and this disease carries a high mortality. In the setting of HHT the abscess most likely results from paradoxical septic emboli or bacterial seeding of an ischemic portion of the brain after paradoxical sterile emboli. Brain abscess is the diagnosis that must be ruled out in patients with HHT presenting with new onset neurologic symptoms. The clinician can be misled by seemingly benign and nonspecific symptoms, signs, and laboratory test results. Appropriate diagnostic imaging with computed tomography or magnetic resonance imaging of the head is mandatory. We present a case of brain abscess in a patient with HHT presenting to the Emergency Department. The review of the literature deals with the pathophysiology and manifestations of HHT with particular focus on the pathologic and clinical features, and management of cerebral abscess in this setting. Differences between patients with brain abscess with or without HHT are highlighted.

Pulmonary arteriovenous fistula and brain abscess

Patients with pulmonary arteriovenous fistulas (PAVFs) are at risk for the development of brain abscesses. The history of a 26-year-old man with PAVF, which has remained unrecognized for many years, is reported. Within four years, the patient presented life threatening cerebral abscesses twice at different sites. Treatment consisted of parenteral antibiotics. Finally, the pulmonary arteriovenous fistula has been treated by embolization. This case emphasizes the importance of early diagnosis and treatment of PAVF in preventing central nervous system infections. Copyright 1998 Lippincott Williams & Wilkins

Screening family members of patients with hereditary hemorrhagic telangiectasia

PURPOSE

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder which may give rise to arteriovenous malformations in lungs and brain. When left untreated, these may cause serious complications. We screened family members of HHT patients for presence of the disease and associated pulmonary or cerebral arteriovenous malformations.

PATIENTS AND METHODS

We investigated 98 family members of HHT patients on an outpatient basis. A stepped screening protocol was used based on prevalence of different manifestations of HHT.

RESULTS

Thirty-six cases of HHT were found in the 98 persons screened. Pulmonary arteriovenous malformations were found in 12 of the 36 patients (33%), and cerebral arteriovenous malformations in 4 (11%). Therapy was recommended in 9 patients with pulmonary arteriovenous malformations and in 2 with cerebral arteriovenous malformations.

CONCLUSIONS

Family members of known HHT patients should be encouraged to engage in a screening program, since the prevalence of potentially serious localizations is higher than previously thought.

Embolic abscesses in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia is an inherited disorder in which patients may have multiple telangiectases and arteriovenous fistulas in the skin and internal organs. Patients can suffer from a variety of serious clinical complications, including abscess formation. We report two patients in whom neurologic symptoms developed from embolic abscesses, one for whom this complication was fatal. The reported incidence and microbiologic features of this complication are similar to that of endocarditis in patients with valvular heart disease. We believe that patients with hereditary hemorrhagic telangiectasia should receive similar antibacterial prophylaxis for procedures placing them at risk for bacteremia.

Age-related clinical profile of hereditary hemorrhagic telangiectasia in an epidemiologically recruited population

We report the results of a comprehensive and systematic clinical study of 324 patients with hereditary hemorrhagic telangiectasia, selected from a total of 1,270 cases recruited by epidemiological survey. In 94% of the cases, familial occurrence suggested autosomal dominant inheritance; maximum penetrance for at least one manifestation was 97%. Epistaxis was reported by 96% of the patients and, in more than 50%, developed before age 20. Heavy and frequent bleeding occurred mainly in middle-aged patients. Telangiectasia was documented in 74% of cases, half of whom were younger than 30 years. The frequency of involvement of the hands and wrists was 41%, and for the face, 33%. Visceral involvement was present in 25% of patients, with affected lungs and CNS in the young and gastrointestinal tract and liver in older patients. Symptomatic urinary tract involvement was seen in only two/324 patients. Involvement of other internal sites was not observed.

Clinical spectrum of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is an autosomal dominant, systemic fibrovascular dysplasia in which telangiectases, arteriovenous malformations, and aneurysms may be widely distributed throughout the body vasculature. Major clinical manifestations include: recurrent bleeding from mucosal telangiectases and arteriovenous malformations; hypoxemia, cerebral embolism, and brain abscess due to pulmonary arteriovenous fistulas; high-output congestive heart failure and portosystemic encephalopathy from hepatic arteriovenous malformations; and a variety of neurologic symptoms due to central nervous system angiodysplasia. Therapy is primarily supportive, consisting of iron supplementation and blood transfusion. Septal dermoplasty and oral estrogens may allow prolonged remission of epistaxis, but permanent surgical cure of gastrointestinal bleeding is rarely feasible because of diffuse angiodysplasia of the alimentary tract. Ligation, resection, or embolization may be indicated for pulmonary arteriovenous fistulas. The prognosis and survival of patients with hereditary hemorrhagic telangiectasia are favorable, providing treatable complications are accurately diagnosed.

[Neurological manifestations of Rendu-Osler-Weber disease. Apropos of 4 cases]

Rendu-Osler-Weber disease is a generalized vascular dysplasia which also involves the central nervous system. The neurological manifestations of the disease are due either to primary intracranial or spinal vascular lesions or to neurological complications of other visceral lesions, notably those of the lung (arteriovenous fistulae). The prevention of ischaemic or infectious cerebral accidents rests on the anatomical (excision) or functional (selective embolization) exclusion of pulmonary arteriovenous fistulae, when present.

Cerebral embolism--first manifestation of pulmonary arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia

Four of five patients with asymptomatic small or moderate-size pulmonary arteriovenous malformation (PAVM) presented with a paradoxical embolus and stroke. In these patients chest radiographic findings were subtle and arterial hypoxemia provided the real clue to diagnosis. Computed tomography (CT) and cerebral arteriography confirmed embolic occlusion in four of five patients. Careful family screening including posteroanterior (PA) and lateral chest radiographs and arterial oxygen determinations in sitting or standing positions are recommended for early detection of asymptomatic patients with PAVM. Early therapeutic intervention (with balloon embolotherapy) is recommended to avoid paradoxical embolization.

High out-put congestive heart failure as first manifestation of Osler-Weber-Rendu disease

We present two cases of hemorrhagic hereditary telangiectasia (HHT) or Osler-Weber-Rendu disease which started as heart failure. Both had multiple arteriovenous fistulas, one of them in a rare localization in this disease, a lower extremity. We conclude stressing the importance of thinking of HHT in the presence of obscure heart failure or arteriovenous fistulas and of looking for internal fistulas when faced by a HHT.

Central nervous system infections associated with hereditary hemorrhagic telangiectasia

The clinical courses of 31 episodes of brain abscess and one episode of meningitis occurring in patients with hereditary hemorrhagic telangiectasia are reviewed. Pulmonary arteriovenous malformations were demonstrable in all but two patients and presumably permitted septic microemboli to evade the normal pulmonary capillary filter and lodge in the brain. Obtundation, headache, visual disturbances, hemiplegia, and seizures were the most common presenting features. Cyanosis, clubbing, polycythemia, and hypoxemia were routinely encountered, but leukocytosis and fever were present in a minority of cases, and all blood cultures were sterile. Anaerobic and microaerophilic streptococci were the commonest pathogens found in the brain abscesses. Thirteen patients died, and patients without abscess drainage or with delayed diagnosis had a higher mortality rate. A brain abscess may develop in approximately 1 percent of patients with hereditary hemorrhagic telangiectasia, and awareness of this risk should lead to early investigation of any patient with hereditary hemorrhagic telangiectasia who has neurologic symptoms.

Spontaneous haemothorax in Osler-Weber-Rendu disease

A case of hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease) is described who presented with severe, central chest pain mimicking acute myocardial infarction, a presentation which has not been described before. He was found to have developed spontaneous haemothorax which is a very rare complication of this disease.

Spontaneous haemothorax in Osler-Weber-Rendu disease

A case of hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease) is described who presented with severe, central chest pain mimicking acute myocardial infarction, a presentation which has not been described before. He was found to have developed spontaneous haemothorax which is a very rare complication of this disease.