Posterior reversible encephalopathy syndrome after intramuscular oxygen-ozone therapy
Viviana Nociti, Chiara Picarelli, Francesco A. Losavio, Giuseppe Reale, Gabriele Giuliano, Giacomo Della Marca, Mario Tumbarello
2020
Canadian Journal of Neurological Sciences
A healthy 66-year-old male was admitted to our emergency room (ER) with fever and severe bilateral visual loss (VL). The day before accessing the ER, the patient had undergone an apparently uncomplicated intramuscular paravertebral cervical injection of 20 ml of an oxygen-ozone mixture (ozone concentration of 20 μg/ml) and lidocaine 2%. It was the penultimate administration of a five-injection cycle of oxygen-ozone therapy (OOT) for the treatment of cervical herniated disc symptoms. About five
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... inutes after the procedure, severe frontal headache, confusion, nausea, and vomiting occurred. Progressive bilateral blindness, memory impairment, and restlessness occurred about half an hour later. Once in ER, one hour after the onset of VL, the patient presented with fever up to 38.5°C. There was no evidence of significant hemodynamic changes. Blood tests showed neutrophilic leukocytosis (WBC count: up to 19630/mmc with 84.6% neutrophils), C reactive protein 19.1 mg/l, and value of procalcitonin in the normal range. Blood cultures were performed. The ophthalmological evaluation was negative; the neurologic examination showed global amnesia, temporal disorientation, and bilateral cortical blindness, with sparing of the pupillary light reflex. A chest X-ray was negative for consolidations or interstitial involvement; the head computed tomography (CT) angiography was negative for major vessel occlusion or ischemia, while magnetic resonance imaging (MRI) showed diffusion-weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) hyperintense lesions in the right cerebellar hemisphere and in the vermis and further alterations in the occipital parietal cortex bilaterally ( Figure 1A and B) with normointense ADC maps ( Figure 1C and D) suggestive of posterior vasogenic edema. Cerebrospinal fluid (CSF) examination showed hyperproteinorrachia (351 mg/dl) and 11 cells/mmc with normal glucose; microbiological samples were negative for Cryptococcus antigen and molecular and direct exam for bacteria. Empiric therapy with vancomycin, ceftriaxone, and acyclovir was administered. At the admission to the department of infectious diseases, 24 h later, the patient was stuporous but easily awakened in response to verbal stimuli, well oriented to place but not in time. Bilateral visual impairment was still present, though an initial recovery of left lateral visual field was reported. Fever ceased on the second day of hospitalization. The antibiotic therapy was continued because of the suspicion of a procedure-related sepsis and maintained for a 14-days cycle; antivirals were continued because of the possibility of an overlapping encephalitis. A full recovery of the visual acuity (20/20 in both eyes) and an improvement of the neurological examination occurred on the 9th day. A transthoracic echocardiogram showed no vegetations, blood cultures performed in the ER were sterile, polymerase chain reaction LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES Volume 47, No. 3 -May 2020 417 https://www.cambridge.org/core/terms. https://doi.
doi:10.1017/cjn.2020.35
pmid:32077386
fatcat:olpemvpg6baglat7upgedze2oi