Cerebral microbleeds in a young patient – case presentation with rare disease association and literature review

During the coronavirus pandemic neurology departments were forced to treat diseases that had hitherto been treated by other specialities. In our case presentation, we describe an unusual association of two diseases that raised interesting questions regarding differential diagnostics and has not yet been presented in the literature.

A 34-year-old male patient was admitted to the neurology department with an urgent referral because of impaired speech comprehension and expression upon awakening. He had a history of anticoagulant therapy for thrombosis of the posterior tibial artery, discontinued after two weeks. Physical examination revealed a 1 cm diameter painful lump in the subcutis of his right thigh and a systolic murmur over the mitral and aortic valves. Nonenhanced head CT showed a small hemorrhage near the occipital horn of the left ventricle, which could not explain the mixed aphasia. In addition, the SWAN MRI sequence showed supra- and infratentorial microbleeds, suggesting cavernomatosis, which was confirmed by the detection of another typical popcorn-like bleeding cavernoma on repeated MRI examination. Due to the heart murmurs and positive inflammatory markers, a detailed cardiac examination was warranted, confirming infective endocarditis caused by Streptococcus gordonii. Due to COVID-19-related regulations the patient couldn’t be transferred to the Department of Cardiology or Infectious Diseases, thus his treatment and follow-up was carried out at the Department of Neurology. Following targeted antibiotic treatment the patient’s symptoms resolved and he underwent successful cardiac surgery 7 weeks after his discharge in a symptom-free state.

The peculiarity of the case lies in the fact that the clinical picture and course of the disease, consistent with the diagnosis of infective endocarditis suggested cerebral septic emboli with microbleeds, but cerebral cavernomatosis was confirmed by brain imaging.