case_images: PMC11321331_01
case_images: MRI and MRA findings obtained on the 2nd day. Symmetric lesions in the frontal, parietal, and occipital lobes and cerebellar hemispheres showed hypointense on T1-weighted images (A, E and I), hyperintense on T2-weighted images (B, F and J) and FLAIR images (C, G and K), isointense or slight hypointense (D, H and L), on DWI. The distal portion of right vertebral artery was visualized ambiguously, and the left vertebral artery presented one aneurysmal dilation (M).
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case_images: T1-weighted images, hyperintense lesions on T2-weighted images, and high-intensity lesions on fluid-attenuated inversion recovery (FLAIR) imaging in the frontal, parietal, and occipital lobes and cerebellar hemispheres. These lesions showed isointense or slight hypointense on diffusion-weighted imaging (DWI) (Figure 1A-L). Magnetic resonance angiography (MRA) provided right vertebral artery tortuosity and aneurysmal dilation in left vertebral artery (Figure 1M). 
case_images: Dynamic evolution of ECG ECG findings obtained on the 4th day (A and B), 5th day (C), 11th day (D). (A) showed slight ST-segment depression in limb leads and bidirectional change in the chest leads. (B and C) showed pathological Q wave in II, III and aVF leads and ST-segment arch like elevation in the chest leads. On the 11th day, all these changes improved (D).
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case_images: Her electrocardiogram (ECG) showed sinus tachycardia and right ventricular hypertrophy, 10 hours later ECG showed dynamic evolution: pathological Q wave in II, III and aVF leads, ST/T-wave changes (Figure 2).
case_images: Urine samples before (A) and after (B) exposure to sunlight. Her urine turned darker and redder upon exposure to light, and improved after 1 day of high-glucose administration (C).
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case_images: Although she had no family history of porphyria, AIP was considered because of the combination of central nervous system (CNS) abnormalities, dysautonomia, abdominal pain and the dark-colored urine, and the urinary porphyrinogen sun exposure detection was made which showing her urine turned darker and red (Figure 3), although urinary porphobilinogen (PBG) and delta-aminolevulinic acid (delta-ALA) could not be tested due to the limited conditions in our hospital.
case_images: Dynamic evolution of MRI and MRA. The lesions observed on the 2nd day (A-D) were improved on the 14th day (F-I). The vasoconstriction observed on the 2nd day (E) spreads to the whole right vertebral artery, ACA, MCA and PCA on the 14th day (J). As with the improvement in the MRI findings, the constriction of right vertebral artery, ACA, MCA, and PCA was nearly normalized on the 36th day (K-O), except the exacerbating of the aneurysmal dilation in left vertebral artery which improved on the 1 year of onset (P-T).
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case_images: Gene analysis revealed a heterozygous Mutation involving intron 11 (c.772-20A>C) of HMBS in the patient (A), the mutation was identified in the patient's father (B), but not in the patient's mother (C) (as shown in red circle).
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case_images: The results of the mutation verification are shown in Figure 5.