After admission, the patient received 4000 U of low-molecular-weight heparin once daily to promote blood circulation and relieve stasis, reduce platelet aggregation, improve valvular function, and prevent infection. After treatment, the lower-limb edema reduced; however, the mass on the lateral right thigh was still palpable. On Day 7 of admission, the patient developed pain in the lateral thigh mass of the right lower limb following intermittent pneumatic compression therapy. Emergency bedside color Doppler ultrasound revealed lower limb muscle edema and no obvious abnormalities in the lower limb vessels. The blood tests were repeated and revealed a leucocyte count of 13.77 × 109/L, comprising 59.5% neutrophils and 26.4% eosinophils; hs-CRP, 8.50 mg/L; D-dimer, 1.28 mg/L FEU; and fibrin (proto) degradation product, 5.40 mg/L.
Following the administration of 10 mg morphine hydrochloride injection subcutaneously, the patient’s pain was relieved. Computed tomography (CT) scan of the lower abdomen revealed right thigh subcutaneous edema of approximately 18 cm × 15 cm adjacent to five further enlarged right deep inguinal lymph nodes, the largest measuring approximately 22 mm × 8 mm. Magnetic resonance imaging (MRI) revealed soft tissue swelling and exudative-like changes in the superior portion of the right mid-thigh, with five enlarged deep inguinal lymph nodes adjacent to the iliac vessels, the largest measuring approximately 24 mm × 8 mm.
On Day 10 of admission, the patient developed extensive erythematous macules throughout the body. Anti-allergic treatment was administered, including dexamethasone 5 mg intravenously (once), 5% glucose injection + calcium gluconate 20 mL intravenous infusion, and loratadine tablets 10 mg once daily orally; anticoagulation treatment was discontinued.
Further diagnostic work-up
The rheumatology and immunology departments were consulted, and color Doppler ultrasound was performed for further examination of the superficial lymph nodes. No obvious enlarged lymph node echo in the bilateral supraclavicular fossae were noticed; however, multiple bilateral axillary lymph nodal echoes were observed, the largest of those measuring approximately 11 mm × 7 mm and 14 mm × 6 mm on the right and left sides, respectively. CT of the chest and upper abdomen revealed bilateral pleural effusion, suspected to be inflammatory exudates (Figure 1); mild enlargement of the bilateral axillary lymph nodes was observed, the largest of those measuring approximately 11 mm × 7 mm and 14 mm × 6 mm on the right and left sides, respectively.
Computed tomography of the chest and upper abdomen reveals bilateral pleural effusion, with suspected involvement of inflammatory exudates.
Blood tests were repeated again on Day 10 and revealed a leucocyte count of 15.58 × 109/L, comprising 46.5% neutrophils and 36.7% eosinophils; eosinophil count, 5.72 × 109/L; platelet concentration, 108 × 109/L; hs-CRP, 32.52 mg/L; erythrocyte sedimentation rate, 28 mm/h; D-dimer, 4.18 mg/L FEU; fibrin (proto) degradation product, 5.86 mg/L; and aspartate aminotransferase (for myocardial enzyme spectrum) 88 U/L; the remaining parameters were within normal limits. Liver function tests revealed alanine aminotransferase, 69 U/L; aspartate aminotransferase, 88 U/L; and serum potassium, 2.96 mmol/L.
A hematology consultation was recommended to further improve the related parameters. The antineutrophil cytoplasmic antibodies, antinuclear antibody spectrum, anticardiolipin antibodies, and direct Coombs test results were all negative, while thyroid function test results were within normal limits. The immune function tests revealed, immunoglobulin E, 348.81 IU/mL; complement C3, 0.83 g/L; and cytomegalovirus IgG antibody, 279.273 AU/L. The leucocyte count was 12.13 × 109/L, comprising 23.1% neutrophils and 58.1% eosinophils; eosinophil count, 7.06 × 109/L; and platelet count, 120 × 109/L.
On Day 14 of admission, the patient was transferred to the rheumatology department for further treatment. Screening tests for gynecological tumors and respiratory viral infections were negative. Bone marrow aspiration and biopsy results were consistent with high eosinophilia and did not support the morphological changes associated with myelodysplastic syndrome, plasma cell myeloma, or lymphoma; the anti-allergic treatment was continued. On Day 15 of admission, rashes over the entire body subsided significantly. Blood tests revealed a leucocyte count of 15.57 × 109/L, comprising 33.4% neutrophils and 53.3% eosinophils; eosinophil count, 8.3 × 109/L; and platelet count, 80 × 109/L.
At 3:00 AM on Day 18 of admission, the patient complained of headache, involuntary movements of the right upper limb, and decreased sensation in both the right limbs; she had no other symptoms, such as diplopia and cough. The results of an urgent cranial MRI + magnetic resonance angiography (MRA) + magnetic resonance venography (MRV) revealed the following (Figure 2): (1) Abnormal signals on the left side at the fronto-parietal junction, indicating the formation of a hematoma; (2) Abnormal signals in the right frontal lobe, indicating the possibility of a small amount of hemorrhage; (3) Hypertrophy of the left inferior turbinate; (4) No obvious abnormalities observed on the MRA scan; and (5) Brain MRV revealing (I) Superior sagittal abnormal changes in the blood vessels above the sinus and in the adjacent areas, indicating the possibility of venous sinus thrombosis and (II) Narrowing in the left transverse sinus compared to the opposite side. The patient was transferred to the neurology department for further diagnosis and treatment.
Abnormal signals on the left side at the fronto-parietal junction, indicating the formation of a hematoma.
Physical examination following the transfer revealed the following findings: bilateral pupils reactive and equidistant, central position of the tongue, reduced muscle tone of the right limbs, right upper limb muscle strength level 2, and right lower limb muscle strength level 3. The pain on the right side decreased, no pathological reflex was elicited, and meningeal irritation sign was negative. The patient underwent a lumbar puncture; the pressure was 230 mm H2O during the procedure; 20% mannitol injection 125 mL was administered every 8 h and citicoline injection 1.0 g was administered once daily.
On Day 18 of admission, an episode of projectile vomiting occurred, along with gradual loss of consciousness and limb stiffness. An urgent head CT revealed increased left frontal and parietal hemorrhage, subarachnoid hemorrhage of 15 mm × 20 mm, midline-shift, and worsening of the brain swelling; the patient underwent neurosurgery on the same day. During the surgery, brain tissue swelling, multiple subarachnoid hemorrhages on the surface, venous congestion and stasis, disappearance of brain tissue pulsation, and a fistula at the superior frontal region with a dark red hematoma at a depth of approximately 1 cm were observed. Anterior and posterior exploration of the hematoma was performed, and it was drained. Venous blood was oozing from multiple points. The bleeding was controlled while removing the dead brain tissue.
After surgery, the left and right pupils measured 3.5 mm and 2.5 mm, respectively, and bilateral loss of response to light was observed. On Day 19 of admission (postoperative day 1), a venous color Doppler ultrasound revealed no thrombosis in the lower limb, and no obvious abnormalities in the heart were observed on the color Doppler ultrasound. Blood tests revealed a leucocyte count of 13.33 × 109/L, comprising 65.0% neutrophils and 9.3% eosinophils; eosinophil count, 1.24 × 109/L; and platelet count, 40 × 109/L. Liver function tests revealed albumin, 25.4 g/L and alanine aminotransferase, 50 U/L.
On Day 20 of admission (postoperative day 2), the blood test results revealed a leucocyte count of 11.03 × 109/L, comprising 78.7% neutrophils and 8.6% eosinophils; eosinophil count, 0.95 × 109/L; and platelet count, 47 × 109/L.