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Page 1: 1igakukai.marianna-u.ac.jp/idaishi/www/334/13-33... · Abstract ACase of Cerebrospinal Fluid Rhinorrhea in a Patient Receiving Hemodialysis Masahito Miyamoto 1,Katsuhide Toyama 1,Goro

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������������� �������45 mg�dl �� ����� Na�Cl ������������������ �Table 1�� ������������ !"�� #$�%�&�'�()*+, '�-.���������: /� 153.0 cm� 01 57.0 kg� 23 138�98 mmHg� 04 36.8�C� �� 90���5��678 16��� 9:;�� <=��>�?�@A�� B�C�D�E�� BFC�GH-�� ��IJKLMN-�� 67O;� POQR-�� ���S��� 3�-�� TOUR� VW��M-�� X�Y���Z[��\]^_�`��a� b�c()d���QR��[-e.��������� �Table 2�: �2F 5,300�ml,CRP 1.0 mg�dl� �f^���ghij������� b�c�kl2� mno���!p�qrQR���`��-e.�� "�#ds$������ tu0vwxJ��Z[QR��[��-e.��

������� �Figs. 1, 2�: $� CT&�yz{%"����|}���0~&��`��� �w��'���( 2 mm�{�����[���� $� MRI &�yz{%"��0~&��%�� T2���_!�&��w��'���)�������_�������*�"����� tu0 MRI+_!�&�tu0�,-� �3 mm� ���� �w���D�����"����~&��[���empty sella � !����� �� �Fig. 3�: .^/�*�����-��M01���n��[��-e.�� ��������������`��� 2'  934�)yz{%����5¡¢�£¤"��� ¢¥��&��w��'��{�,-��Y������[��� 6�¦������§¨�©����� ª«{�yz{%¬7��­8��7��®¯�IJ°±w��9��¤}��� ¢�� �����-�  2334�²'�-.�� 2�³��:�¢� 1´µ�2�;¶ m�<=���

Table 2. Laboratory Examination Data on Admission

Table 1. Findings of the Cerebrospinal Fluid and the Rhinorrhea

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����� Ommaya �1����� ����� �a� ������� b� ����� �� �����c� ������ d� ����������� �������������� !"�� focal

atrophy� #�$%&� ������'()*+%&�, -�� .%/0��1 empty sella ������-23�������45���� 67��� 89�������,&:�23-���;<=&� �����-2�����>45�� ?�@A�����B� 2�4 C3D�2��

Fig. 1. Brain CT �A: Axial view B: Sagittal view�Brain CT shows the bone defect at the base of sella tucica�arrow� and the cerebrospinal fluid pool inthe spenoidal sinus.

Fig. 2. Brain MRI �A: Axial, T2WI. B: Sagittal, T2WI C: Coronal, T2WI�A: The cerebrospinal fluid pool in the spenoidal sinus�arrow�.B: The cerebrospinal fluid leaks from the base of sella tucica as a line high intensity�arrow�.C: Thinning of the pituitary gland and the cerebrospinal fluid pool in the sella tucica is seen�arrow�. Itsuggests an empty sella.

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���������������� ������������3��������������������� ���� ��!"�� 2 ����#�� Ozveren$4��� 53 % 18 &'���(�)�������������������� PTH �216 pg�dl� *+,-.�/01� 65.72 23��4567� 89�:�� ��; Ca �<� 7 mg�dl2=>�?�"� @ABC� empty sella ��D�� 2 3��4567� 89��EFGHI�� JKFFLM��������NO�P#�Q2RS�?T�� UV$5�� 39%)���7�W����� ��X��������� 1����?T�� ����Y������Z[���2\$� ������EJK]^ 8�������9NO_2`�P#�2ab?T�� cd� Arie# $6�ef��T��g��� ��hY��i�^�� 20�40 mmH20 \$ 220�240mmH20 ���Zj��2��?T�� k$� 1lW 40�mnP����� h 50 mmH2O \$Y280 mmH2O� 3 lW 20 �opP����h 60mmH2O\$Y 220 mmH2O2� mnP��qE�opP��r"Q�i�^=>s<�t\#�2ab?T�� �9���� PTH � 110 pg�dl� *

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Fig. 3. Clinical course of the patient.

PAPM: panipenem MEPM: meropenem

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empty sella ���������� ��� 2 �������������������� ������ ����� ������ ��!��"#���$��%&�'� (�� �� 10 7)�� 5 *�+,-.�/012(3'�� empty sella ��45678�0���9�:�9��� -.�/��4�;<=���>��9�0?@(3�:�>AB��C�<.���D�����EF��primary empty sella ��G��H% 6�24�� X� CT % 11�38�� MRI % 2�14�������I(3J48�� KLM���N� �O�/PM�J'3��Q(3'�'��0�R$S����EF�� -.�/PM%<.���empty sella >�C��I��T44�� -.�/PM�J'3 !��"UVW��0��X����-YZ[�#$%T�0� empty sella \<.���]%�^&�_`a'�T��()0T�� b�� empty sella >�C�X��� cd��!��"#���e'0()��4� -.*f� -.*f�/� +,�/�g��;<=�hi�j�'-.k�'-l��m�H.S�n&opq�

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1� Ommaya AK, Chiro GD, Baldwin M and Pen-nybacker JB. Non-traumatic cerebrospinal

fluid rhinorrhoea. J Neurol Neurosurg Pschia-

try 1968; 31: 214�225.2� Dunn CJ, Alaani A and Johnson AP. Study onspontaneous cerebrospinal fluid rhinorrhoea:

its aetiology and management. J Laryngol Otol

2005; 119: 12�15.3� V45� y67z� {89|� y8}:� "~�;� "<=>� ?�<�@� �A��� ����� B� 28����9�C��<.������ 5��t� 2004; 14: 58�63�

4� Ozveren MF, Kaplan M, Topsakal C, Bilge T,Erol FS, Celiker H, Akdemir I and Utida K.

Spontaneous cerebrospinal fluid rhinrrhea as-

sociated with chronic renal failure. Neurol Med

Chir 2001; 41: 313�317.5� ���D� ����� �?��� �EF� �<��� �G%��9� ���<,G� 1e��� �VW�� 1985; 13: 425�431.

6� Arie# AI, Massry SG, Barrientos A and Klee-man CR. Brain water and electrolyte metabo-

lism in uremia: E#ect of slow and rapid hemo-

dialysis. Kidney Int 1973; 4: 177�187.7� ��K� HI�. Empty-Sella � ¡� ¢6£¤�J¥ 2001; 49: 1061�1064.

8� {�¦§� HI�� �<KF� ¨¤©ª«¬­� ¡� 2/JL 1993; 51�®¯°:/MJ¥N±x�²�: 39�44.

9� 8�³´� µ¶O� ¶~·�� �6P¸� ¹¶�Q� º»R¼� ST�<.��>�9� Pri-mary empty sella � 1e��� |Htu 1992;45: 1650�1655�

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Abstract

A Case of Cerebrospinal Fluid Rhinorrhea in a

Patient Receiving Hemodialysis

Masahito Miyamoto1, Katsuhide Toyama1, Goro Imai1, Satoshi Kondo1,

Tadahisa Tomohiro1, Hiroki Tsuchida2, Yoshio Taguchi3, and

Kenjiro Kimura2

Case Report: A 47-year-old woman, who was being treated for six years with hemodialysis for end stage

renal disease from chronic glomerulonephritis, was admitted in June 2003 to the related hospital with

complaints of headache and nausea after hemodialysis. She had been experiencing significant nasal discharge

and pyrexia for approximately six months. Laboratory examination showed a white blood cell count of

11100�ml, CRP; 6.29 mg�dl and cerebrospinal fluid�CSF� cell count of 3432�ml. The nasal discharge findingswere consistent with CSF rhinorrhea. After treatment of meningitis by antibiotics, she was transferred to our

hospital.

Further evaluation was performed after her transfer, and a bone defect at the base of sella tucica �about2 mm� and CSF leakage were detected on brain CT and MRI imaging. Furthermore, an empty sella wasfound. Trans-sphenoidal reconstruction of the sella floor completely alleviated all of the symptoms.

In this case, there was no past traumatic episode, and it was speculated that the empty sella might be the

cause of the CSF rhinorrhea. Although CSF rhinorrhea with an empty sella is rare in hemodialysis patients,

it should be considered as a complication, if neurological symptoms such as headache are found in the

patients.

1 Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of

Medicine Yokohama City Seibu Hospital 1197�1 Yasashi-cho, Asahi-ku, Yokohama 241�0811, Japan2 Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of

Medicine

3 Department of Neurosurgery, St. Marianna University School of Medicine Yokohama City Seibu Hospital

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