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A Mauritian woman with fever, abdominal pain, and facial palsy
  1. P Gyawali,
  2. D Agranoff,
  3. D C Macallan
  1. Department of Infectious Diseases, St George's Hospital Medical School, London SW17 0RE, UK
  1. Dr Macallan

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Answers on p 540.

A previously well 43 year old woman of Mauritian origin presented to the surgeons with abdominal pain, nausea, and vomiting occurring over a period of eight weeks. She described it as a band-like constricting sensation encircling the upper abdomen and lower chest. Six weeks previously she had suffered a right lower motor neurone facial nerve palsy, which had resolved spontaneously. There were no respiratory symptoms. She had been exposed to tuberculosis at the age of 2 before immigrating to the UK. She was on no regular medication, and did not smoke or drink alcohol.

On examination she had a low grade fever and was tender in the epigastrium. There was no obvious BCG scar. She had altered sensation to light touch and pinprick in the lower thoracic and upper abdominal dermatomes. She had modestly deranged liver function tests: bilirubin 9 μmol/l, alanine transaminase 86 U/l, alkaline phosphatase 321 U/l, and amylase 417 IU/l but her full blood count and urea and electrolytes were normal. She was admitted for further investigations. Five days after admission she complained of weakness in the left leg and was found to have impairment to light touch and pinprick sensation over the knee with loss of the left knee reflex. This was rapidly followed by development of a left lower motor neurone VIIth nerve palsy on the opposite side to the previous lesion. In view of her past exposure to tuberculosis and persisting low grade fever, she was transferred to the care of the infectious diseases team for further evaluation.

Chest radiography showed paratracheal lymphadenopathy but induced sputum was negative for acid-fast bacilli and she had no reaction to a tuberculin skin test (10 units). Percutaneous liver biopsy was undertaken and histology is shown in fig 1. A magnetic resonance scan of the spine is shown in fig 2. An ultrasound scan showed diffuse echogenic abnormality in the liver.

Figure 1

Liver biopsy specimen (original size × 400).

Figure 2

Sagittal gadolinium enhanced magnetic resonance scan (T2 weighted).

Questions

(1)
What is the likely diagnosis and what supportive investigations would be helpful?
(2)
What further test should be performed to help guide management?

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