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case_images: Digital clubbing.
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case_images: The patient was a 38-year-old male who had a history of difficult to control convulsive crises since childhood and arrived at the intensive care unit (ICU) with tachypnea and dyspnea and cyanosis of the extremities, in addition to significant nail clubbing (Figure 1).
case_images: Computed tomography of the head without contrast, showing hypoattenuation of the right cortico-subcortical frontal and left temporal regions and ectasia of adjacent cortical sulci and lateral ventricles, suggestive of encephalomalacia/gliosis.
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case_images: Work-up was initiated with computed tomography (CT) of the head without contrast (Figure 2), showing hypoattenuation of the right cortico-subcortical frontal and left temporal regions and ectasia of adjacent cortical sulci and lateral ventricles, suggestive of encephalomalacia/gliosis, compatible with the patient's family's report of neurosurgery to treat a cerebral abscess at 9 years of age, explaining the patient's neurological status at admission, and characteristic of structural epilepsy secondary to surgical manipulation.
case_images: Pulmonary radiological examination. In A) chest X-ray showing arteriovenous malformation (AVM) in the apical segment of the upper right lobe (URL) - white arrow - and the apical segment of the right lower lobe (RLL) - black arrow; in B and C) computed tomography (CT) of the chest with contrast showing AVM in the URL; and in D, E, and F) chest CT with contrast showing AVM in the RLL and the apical segment of the left lower lobe.
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case_images: After clinical stabilization, the patient was sent for chest CT with contrast (Figure 3), showing a right-side pulmonary vascular malformation, with ectatic and tortuous structures vascular following an intraparenchymal path in the upper segments of the RLL and URL and communicating with the pulmonary artery and veins on the right, suggesting an arteriovenous malformation (AVM).
case_images: Hepatic arteriovenous malformations seen on upper abdominal ultrasonography.
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case_images: These hepatic changes were also observable on upper abdominal ultrasonography (Figure 4).
case_images: Transthoracic echocardiography with no direct signs of pulmonary arterial hypertension.
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case_images: Transthoracic echocardiograms (Figure 5) were performed by three specialists at different times and showed no indirect signs of pulmonary arterial hypertension (PAH), such as enlarged right cardiac chambers, paradoxical interventricular septal movement, tricuspid valve reflux, abnormal tricuspid annular plane systolic excursion, or elevated systolic pulmonary artery pressure.