A Pregnant Woman with Headache

Posted by • September 18th, 2015

Axial MRI Scans of the Head.In a new Case Record of the Massachusetts General Hospital, a 38-year-old pregnant woman presented with headache and visual symptoms. MRI of the brain revealed multiple small infarcts, with no thrombosis. Anemia and eosinophilia were present, as was abnormal endocardial material on echocardiography. Diagnostic tests were performed.

Geophagia is practiced in Guatemala and even encouraged during pregnancy as a desired nutritional supplement. Pregnancy-related geophagia (the habit of eating clay or earth) is a potential source of helminthic infection.

Clinical Pearls

• What are some of the causes of pregnancy-associated ischemic stroke?

Ischemic stroke is uncommon during pregnancy, although there is a high relative increase after delivery (relative risk, 8.7). The rate of both ischemic and hemorrhagic strokes during pregnancy may be increasing, perhaps because of increased rates of hypertension and heart disease. Normal pregnancy leads to changes in hemodynamic function, vascular-wall structure and integrity, endothelial function, and the levels and function of procoagulant and anticoagulant proteins that are factors associated with an increased risk of stroke. The most common causes of pregnancy-associated ischemic stroke are cardioembolism, preeclampsia and eclampsia, and cerebral venous sinus thrombosis. Acquired or inherited underlying hypercoagulability may exacerbate the physiologic prothrombotic state that occurs during pregnancy. Atherosclerosis may also contribute to the risk of stroke in patients with risk factors for early-onset disease.

• What are some of the causes and consequences of hypereosinophilia?

Eosinophilia can be caused by the primary hypereosinophilic syndromes or by secondary causes, including parasitic and viral infections, drug-induced and other allergic causes, and lymphoma and other tumors. Current criteria for a diagnosis of the primary hypereosinophilic syndrome include eosinophilia (>1500 cells per cubic millimeter) that has persisted for 6 months, the absence of secondary causes of eosinophilia, and end-organ involvement. Damage to the heart due to either primary or secondary hypereosinophilia can be manifested by eosinophilic endocarditis (Loffler’s endocarditis) or endomyocardial fibrosis (Davies’ disease).

Morning Report Questions

Q: How is hookworm infection acquired?

A: Hookworm, which is present in New England, is usually acquired through penetration of the skin by larvae from contaminated soil but can also be acquired through ingestion. Adult worms cause a chronic intestinal infection that is accompanied by low-level eosinophilia (500 to 700 cells per microliter). Adult worms damage intestinal capillaries and consume 0.03 to 0.20 ml of blood per day, causing iron deficiency anemia. Diagnosis is determined by means of stool examination for ova and parasites, with a single examination reportedly having approximately 80% sensitivity.

Q: What symptoms are commonly associated with toxocara infection, and how is it treated?

A: Toxocara canis and T. cati infect dogs and cats throughout the United States. Toxocara species are acquired through the ingestion of contaminated soil or infected meat. Larvae hatch in the intestine and migrate through the bloodstream to multiple organs, including the liver, spleen, lungs, and eye. Symptoms commonly include wheezing, fever, hepatomegaly, and eosinophilia and occasionally include cough, urticaria, pruritus, pneumonia, and anemia. The treatment of choice for both toxocara and hookworm infection is albendazole. Treatment of toxocara infection may also include glucocorticoids.

Table 2. Potential Parasitic Causes of Hypereosinophilia in this Patient.

One Response to “A Pregnant Woman with Headache”

  1. Mario Turati says:

    Can you explain “visual simptoms”.