Case Presentation:
A 56 year‐old man with a remote history of skin cancer presented with one month of worsening headaches, nausea and vertigo. He underwent a MRI of the brain in the emergency department which revealed multiple ring enhancing parenchymal lesions with associated edema and local mass effect. He was subsequently transferred to our Hospital’s Oncology service with concern for metastatic disease.
Temperature was 100.5 F but all other vital signs were normal. He had an unsteady gait, tangential speech and was confabulating. Multiple telangiectasias were noted on skin exam. There was no appreciable murmur and his lungs were clear to auscultation. White blood cell count was 14,000, hemoglobin 15 g/dl and platelets were 242,000. Comprehensive metabolic panel was fairly unremarkable. Chest X‐ray showed a 3.6 x 3.0 cm left lower lobe mass and a 2.2 x 1.4 cm right lower lobe nodule. The patient underwent a CT scan of the chest, abdomen and pelvis which revealed multiple nodular lesions with abnormal connection to the pulmonary arteries consistent with arteriovenous malformations but no evidence of malignancy. A transthoracic echocardiogram revealed a left‐to‐right shunt.
Neurosurgery performed a posterior fossa craniotomy and left temporal craniotomy for evacuation and biopsy of the brain lesions with differential diagnosis of abscesses versus metastatic disease. Lesions within the right cerebellum and left temporal lobe contained necrotic and purulent debris. Postoperatively, he was started on empiric broad spectrum antibiotics while awaiting pathologic analysis. Cultures from these lesions grew beta hemolytic streptococci. Biopsies taken from the lesions were negative for malignancy. He was transitioned to IV ceftriaxone and received eight weeks of therapy. He underwent embolization of the noted pulmonary arteriovenous malformations (PAVMs) by interventional radiology to avoid any future embolic phenomena. His mental status returned to baseline and he reported improvement in nausea and vertigo prior to discharge.
Discussion:
Pulmonary arteriovenous malformations are abnormal connections between the pulmonary arteries and veins that can lead to fatal consequences if not recognized early. PAVMs are uncommon and most often congenital. Nonetheless it should be kept in mind for common complaints and problems encountered by Hospitalists including dyspnea, hemoptysis, hypoxemia and pulmonary nodules. PAVMs should especially be considered in cases of a new stroke or brain mass in setting of a chest x‐ray with masses or large nodules. Approximately 70% of individuals with PAVMs have underlying hereditary hemorrhagic telangiectasias (HHT). Hence, it is important to ask about a family history that may suggest HHT. It is also important to ask about a history of epistaxis and perform a skin exam looking for telangiectasias. A contrast echocardiogram to assess for left to right shunt is a good initial test when the diagnosis is suspected. Patients found to have PAVM sacs greater than 2 cm in diameter, or PAVMs that have feeding vessels that are 2 to 3 mm or greater should be referred to interventional radiology for possible embolization.
Conclusions:
This case highlights the diagnosis of PAVMs which is uncommon but should not be missed by hospitalists. Early diagnosis and treatment can prevent significant complications for our patients including brain abscess, stroke, or hemoptysis.