Recurrent cerebral abscess in hereditary hemorrhagic telangiectasia

Pulmonary Arteriovenous Malformations and Cerebral Abscess Recurrence in a Child With Hereditary Hemorrhagic Telangiectasia

BACKGROUND

A 17-year-old boy was referred to our center with a history of brain abscess (BA) recurring after 9 years. The patient reported 2 previous treatments for pulmonary arteriovenous malformations, sporadic nosebleeds, and familial history for epistaxis. Clinical investigations revealed arteriovenous malformations in lung, brain, and liver, as well as mucocutaneous telangiectases. A definite diagnosis of hereditary hemorrhagic telangiectasia was made based on clinical criteria and confirmed by genetic analysis. This is the first report of BA recurrence at the end of pediatric age.

CONCLUSIONS

The present case and the literature review of all cases of BA thus far reported highlight the need to raise the suspicion of a pulmonary arteriovenous malformations, both isolated and in the context of a possible hereditary hemorrhagic telangiectasia, for any case of BA of unexplained etiology, in children as well as in adults.

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.

Rendu-Osler-Weber disease: update of medical and dental considerations

Rendu-Osler-Weber disease, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant inherited disorder characterized by an aberrant vascular development. The reported prevalence is approximately 1 per 5,000-10,000. The clinical manifestations consist of recurrent spontaneous nosebleeds, telangiectasias characteristically at the lips, oral cavity, fingers, and nose, and visceral arteriovenous malformations. Timely recognition of this syndrome makes screening for complications, preventive measurements, and genetic counselling possible. The important role of the dental profession in the recognition of this genetic disease is emphasized. In addition, a brief overview of the current literature is presented.

Recurrent brain abscesses in an HIV-positive patient with hereditary hemorrhagic telangiectasia and arteriovenous malformations of the lung

Patients with hereditary hemorrhagic telangiectasia are at risk for the development of brain abscesses. The history of a 47-year-old man infected with the human immunodeficiency virus and with hereditary hemorrhagic telangiectasia is reported. Within eight months, the patient presented twice with life-threatening cerebral abscesses at different sites. On both occasions, Streptococcus anginosus was cultured from the abscess material. Treatment consisted of parenteral antibiotics and neurosurgical drainage. After treatment of the second occurrence, the patient was placed on a prophylactic regimen of clindamycin. He remains relapse-free and is clinically stable 24 months after the second episode.

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.

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.