Description

A 70-year-old woman with nephrotic syndrome (NS) secondary to membranous glomerulonephritis on immunosuppressive therapy, diabetic nephropathy and hypertension presented with sudden hearing impairment.

She had lost the ability to understand speech and transiently expressed some meaningless words. Reading and writing skills were preserved, and she was able to understand written commands.

Audiometry revealed mild bilateral sensorineural hearing loss.

Brain MRI showed a recent left temporal ischaemic lesion (figure 1; white arrow) and right temporal, left occipital and left cerebellar old ischaemic infarcts (figure 1; yellow, green and red stars, respectively). Routine laboratory tests showed low serum albumin, hyperlipidaemia, normal renal function and proteinuria. Doppler ultrasound revealed normal supra-aortic vessels blood flow. No embolic arrhythmia was documented.

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Figure 1

Brain MRI showing a recent left temporal ischaemic lesion.

A diagnosis of verbal auditory agnosia (AA) due to bilateral ischaemic temporal stroke was made. Neuropsychological evaluation was performed in order to plan an intensive speech rehabilitation programme. The patient's clinical condition improved progressively.

AA can be caused by ischaemic or haemorrhagic stroke, viral infection, traumatic head injury, cerebral congenital malformations or tumours. Cortical ischaemic stroke is more commonly caused by atherothrombotic or thromboembolic events. Diabetes and hypertension drive atherosclerosis, resulting more frequently in lacunar infarcts. NS is an additional hypercoagulable state leading to thrombosis that contributed to cause recurrent strokes in our patient, and this is why anticoagulation treatment was started.

Thrombosis in patients with NS occurs more frequently than in the general population.1 ,2 The risk of thrombosis is related to the degree of hypoalbuminaemia and is higher in patients with membranous nephropathy.1^–3 The optimal management of hypercoagulability in nephrotic syndrome is controversial. Anticoagulation treatment should be considered and individualised on the basis of the presence of associated thrombotic events and the risk of bleeding.