Case report

A 48 year old local government officer was admitted to the Medical Eye Unit of St Thomas’ Hospital after the sudden onset 13 days previously of blurred vision with headache. Investigation at another hospital had disclosed a right homonymous central scotoma, and brain CT had shown haemorrhages in both occipital lobes.

There had been no previous neurological symptoms and no other symptoms were noted on systematic enquiry. On examination he was afebrile and there was no lymphadenopathy or organ enlargement. Examination of the heart, lungs, joints, and abdomen was normal. There were no skin lesions. Neurological examination was normal apart from the right homonymous central scotoma. The fundi were normal.

Erythrocyte sedimentation rate was 51, haemoglobin 13.5 g/dl, white cell count 13.4, and biochemical screening was normal. Brain MRI showed eight haemorrhagic lesions of varying age throughout both hemispheres (fig 1). Chest radiography showed three coin lesions. An MR angiogram of the large intracranial vessels was normal and a four vessel arteriogram did not show any vascular abnormality or tumour circulation. An echocardiogram, coagulation studies, antinuclear, extractable nuclear antibodies, and ANCA were negative, and complement studies were normal.

Seven days after admission he developed pleuritic chest pain and a cough productive of blood stained sputum. A ventilation-perfusion scan of the lungs showed multiple matched defects throughout both lung fields. Haemoglobin fell to 10.7 and erythrocyte sedimentation rate rose to 102. …