Intraventricular Hemorrhage in a Patient With Eosinophilic Granulomatosis With Polyangiitis

Abstract

INTRODUCTION: Hemorrhagic stroke is an uncommon manifestation of eosinophilic granulomatosis with polyangiitis. We present a case of altered mental status in a patient with sinusitis and asthma. CASE PRESENTATION: The patient is a 57 year old Egyptian woman with past medical history of asthma, CHF, DM, HTN, and ischemic CVA who presented to the ED with a chief complaint of altered mental status. CT of the head showed intraventricular hemorrhage and sinusitis. Of note, she was discharged the previous day after treatment for community acquired pneumonia confirmed by the presence of bilateral infiltrates on chest imaging. Cerebral angiogram showed a fusiform aneurysm from a branch of the left posterior cerebral artery, which was too small for endovascular intervention. Debridement of the sinuses was performed and biopsy showed numerous eosinophils and lymphoplasma cells. Peripheral eosinophilia (40%) was noted. Infectious work up was negative. Inflammatory work up revealed positive p-ANCA. A diagnosis of eosinophilic granulomatosis with polyangiitis was made based on ACR guidelines and the patient was treated with systemic corticosteroids. DISCUSSION: Eosinophilic granulomatosis with polyangiitis is a small and medium vessel vasculitis characterized by chronic rhino-sinusitis, asthma, and peripheral blood eosinophilia. Neurologic effects are common and usually include mononeuritis multiplex or sensorimotor peripheral neuropathy (1). CNS involvement is unusual and often presents as ischemic infarction or encephalopathy (1,2). Hemorrhagic stroke is rare with few reports in the literature of subarachnoid hemorrhage, intracerebral hemorrhage, and recurrent spinal SAH (2). To date, there is one case report of SAH and intraventricular hemorrhage caused by necrotizing vasculitis of the choroid plexus (3). CONCLUSIONS: This is a rare case of a patient with a long history of asthma and sinusitis presenting with intraventricular hemorrhage precipitated by vasculitis associated with eosinophilic granulomatosis with polyangiitis.