A 71-year-old woman was admitted to the hospital complaining of intermittent fever for two months. Her temperature was 37.5–38.5 ℃ during the two months, but she had no cough, expectoration, abdominal pain and diarrhea. The result of the COVID-19 nucleic acid test was negative. At first, she was diagnosed with urinary tract infection and received anti-infective treatment (penicillin, cephalosporins and glucocorticoids). Her temperature can return to normal temporarily. Once the drugs were stopped, her temperature rose again. Six years ago, she started manifesting with the symptom of frequent urination, nocturia, unstable walking, bradykinesia and shouting at night. She was diagnosed with cerebellar atrophy four years ago and did not improve after symptomatic treatment. Walking instability gradually worsened and laryngeal stridor for two years. One year ago, she had a fever for the first time, lasting for about one month (July-August), with a temperature about 38.0 ℃. Meanwhile, she had unstable handheld objects, urinary incontinence and constipation. Forty days ago, she was in bed with fever, dysphagia, barylalia and no sweat, the range of temperature is 37.0–38.0 ℃. Her husband stated that she had pale skin for fifteen years and hyperthyroidism for six years. Hypertension, diabetes, heart disease and other diseases were not present. She had no infectious or genetic disease, no operation, and no bad personal habits. Her husband and children are healthy.
On physical examination, the vital signs were as follows: T: 37.0 ℃, P: 68 beats/min, R: 24 beats/min, irregular breathing rhythm, laryngeal stridor, BP: 99/66 mmHg (supine position), 104/63mmHg (sitting position). The whole body was pale (Fig. 1). The breathing sound of both lungs was thick, and there were no scattered dry and wet rales in both lungs. Her abdominal examinations were normal. On neurological examination, she was conscious but can not cooperate with the examination. Bilateral pupils were equal in size at 3.0 mm, which was sensitive to the light reflex. The muscle strength was at grade Ⅱ and hypomyotonia. The muscle tension was weakened. Bilateral Babinski signs were positive.
Routine blood analysis showed mild anemia. Urinalysis showed urine protein + 2, white blood cell: 463.40 /µl and red blood cell: 317.30 /µl. Albumin, creatinine and blood urea nitrogen were below normal. Blood glucose was 5.57mmol/L. The hormone levels were shown in Table 1. No obvious abnormality was found in other biochemical indexes. Klebsiella pneumoniae was cultured in urine. Gram positive cocci were cultured in blood. Acinetobacter baumannii, Candida Creutzfeldt were cultured from sputum, and there was no mycobacterium tuberculosis. All cultured bacteria had nothing to do with the patient’s condition. Cerebrospinal fluid showed no evidence of intracranial infection or other diseases. Thoracic puncture, bone puncture and hepatic cyst puncture did not find any infectious evidence. Common infectious diseases that caused fever were excluded (such as typhoid, tuberculosis, rheumatic immune diseases, AIDS, syphilis, tumor and Rickettsia infections).
Table 1. The level of pituitary related hormone. Red arrow: below the normal level.
Electrocardiogram showed sinus bradycardia and one-stage atrioventricular block. Multiple gallstones were found by abdominal CT. PET-CT showed no sign of a tumor. No obvious abnormality was found on CT of the urinary system and pulmonary. Cranial CT showed the obvious atrophy of the brainstem and cerebellum, and T2-weighted image (T2WI) demonstrated the HCB, a specific sign for MSA-C[10, 11]. MRI of the pituitary showed normal (Fig. 2).
After the whole hospital consultation, MSA was a disease that can not be ignored. Based on cerebellar dysfunction and urinary incontinence, the patient finally was diagnosed as probably MSA. Her temperature returned to normal after taking bromocriptine. The patient also was found to have intractable hyponatremia after admission. According to the hormone level, the endocrinologist considered that the patient may also have hypopituitarism, and suggested her receiving the treatment of hydrocortisone. At discharge, her temperature and blood sodium returned to normal (Table 2). She could simply communicate with her family, but she was still in bed with a gastric tube and catheter. Three months later, she passed away at home by a phone follow-up.
Table 2. Changes in vital signs and sodium during hospitalization.