MANILA DOCTORS HOSPITALDEPARTMENT OF INTERNAL MEDICINE

667 United Nations Avenue1000 Manila, Philippines

Case Protocol

The Seafarer’s Wife

Moderator:

Reactors:

Dr. Astejada

Dr Dioquino

Dr Roman

Dr Salvana

Presentor:

Olivia Faye J. Listanco, M.D.

Medical Resident, Yr Level I

CASE PROTOCOL

Objectives:

1) To present a case of a patient with HIV presenting with neurologic deficit 2) To discuss the diagnosis and management of intracranial mass in an HIV patient

This is a case of COV, 46, Female, from Tagytay City, Cavite, Married, Roman Catholic, and works as a fitness instructor. She was admitted at Manila Doctors Hospital last April 4, 2015.

Chief Complaint: Unsteady gait

History of Present Illness

Three months PTA, patient was noted to have weakness of her right arm described as inability to carry her child. She denied any history of trauma. Patient then sought consult at a local hospital where patient was advised to undergo a cervical CT scan. Patient claimed she was then diagnosed to have brachial plexus palsy. She was advised to undergo rehabilitation therapy which she underwent for 3 sessions with noted improvement of her grip strength.

One week PTA, patient then experienced light headedness associated with unsteadiness of gait and tendency to fall. She denied any weakness, slurring of speech or headache at that time.

Symptoms persisted until three days PTA, patient decided to seek consult at Tagaytay Hospital where patient was subsequently admitted for work up. Patient claimed that laboratory tests done yielded normal results. She was then advised to have cranial CT scan done hence decided to transfer to MDH.

Past Medical History: (-) Hypertension, (-) Diabetes, (-) Bronchial asthma, (-) Allergies, (-) previous PTB treatment; (-) previous surgeries; (-) known head trauma, (+) treated for oral thrush and generalised skin dermatitis last January 2015

Personal/Social history:Married to a Mexican national who works as sea manFond of eating raw fish and sea food in the Philippines and at Mexico Non-smoker; occasional alcohol beverage drinker; no known illicit drug useClaimed 2 sexual partners (first husband (deceased) and current husband)Used to work in Africa for 10 yearsFrequently travels to Mexico

Family History:(+) T2DM - mother(-) hypertension, (-) cerebrovascular accidents, (-) cardiac disease

ROS:(-) fever (-) behavioural changes(-) anorexia (-) chest pain(+) Anorexia since last January with unqualified weight loss

Physical Exam at the ER:

BP: 120/70 HR: 80 RR: 20 Temp: 36.5 GCS15Non labored breathingPink conjunctivae, anicteric sclera. (-)CLADNo retractions, equal chest expansion; Clear breath sounds

Adynamic precordium, distinct heart sounds, no murmurs appreciatedAbdomen flat, normoactive bowel sounds, nontender, no evident masses palpableNo gross joint deformities; no gross skin lesionsFull and equal peripheral pulses; no edemaSkin warm, dry

Laboratory tests done included CBC, BUN, creatinine, lipid profile, FBS, and SGPT. Other electrolytes were not done since were already done from previous hospital. Cranial MRI with contrast and 12 lead ECG were also requested.

Admitting Impression: D7 Cerebellar infarct, R/O Cerebellar mass; Brachial nerve palsy

Course in Wards:

1st Hospital Day:Patient admitted at the floors and managed as a case of cerebellar infarct. No reports of headache or

slurring of speech noted. Patient remained with stable vital signs.

Neurological Exam:MSE:

Frontal: Awake, alert, coherent, intact speechParietal: No R-L disorientation, (-) finger agnosia, (-) AcalculiaTemporal: Intact recent, remote, and immediate memory, oriented to 3 spheresOccipital: Able to recognize familiar objects

Cranial nervesCNI: IntactCNII: both pupils 2mm briskly reactive to light, visual field intact; fundoscopy not doneCNIII, IV, VI: primary gaze at midline, full EOMsCNV: intact V1-3, good masseter toneCNVII: no facial asymmetryCNVIII: intact gross hearingCNIX, X: good gag, uvula at midlineCNXI: Good shoulder shrug and SCM toneCNXII: tongue at midline

Motor: 5/5 on bilateral lower extremities, 2-3/5 on right upper, and 5/5 on left upperSensory: 100% on all extremitiesDTR: 2+ on allCerebellar: No dysmetria, dysdiadokinesiaPosterior Column: unsteady gait, tendency to fall on either side, Romberg not doneNeck supple(-) Babinski (-) Clonus

Patient was put initially on complete bed rest without bathroom privileges and started on DAT. Medications started included Citicholine 1g IV q12, Vitamin B complex tab BID, Betahistine 16mg OD, Pregabalin 75mg OD, and Atorvastatin 20mg ODHS.

Patient was seen by the Neurology service and cranial MRI was requested with emphasis on the cerebellum and craniovertebral junction. ESR and VDRL were also requested. Betahistine was increased to BID and Methylcobal 1 tab TID was started.

2nd HD:

Patient was noted to have one episode of twitching of her right upper extremity lasting for less than 3 minutes. No associated loss of consciousness. Vital signs remained stable and patient was seen after the seizure to be awake, and oriented. Patient was also noted to have a shallow left nasolabial fold and tongue deviation to the left.

Patient was put on seizure precaution. Started on Leviteracetam 500mg/tab BID and diazepam 5mg/IV PRN for frank seizure. EEG was also requested. Impression at that time was T/C Seizure disorder probably post-ictal, T/C Subacute infarct, probably right capsuloganglionic versus posterior circulation; Brachial nerve palsy, T/C Stroke in the Young

3rd HD:

Patient had no recurrence of seizure. VS remained to be stable and neurologic deficits were unchanged. Cranial MRI preliminary results revealed two granulomatous lesions left occipital and right parietal with surrounding vasogenic edema. Neurology service the started the patient on Dexamethasone 5mg IV Q8 and Leviteracetam was continued. Patient was then referred to IDS service for co-management with the impression of Intracranial Mass Probably sec to Opportunistic infection, R/O Herniation syndrome R/O HIV infection

4-5th HD

Vital signs remained stable and without noted progression/ new onset deficits. IDS service requested for HIV screening (code 173) as well as other work up which included Chest x-ray, TPHA (quantitative), Toxoplasma IgG and IgM and PPD test. Patient was also started on Ceftriaxone 2gm IV Q12 and Metronidazole 500mg IV Q6. Revised impression was Intracranial mass probably secondary to infection Prob 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4. Tuberculoma; R/O Herniation syndrome

6th HD:

Patient’s neuro status and vital sign remained stable. EEG results showed intermittent slowing of background activity over frontal region suggestive of focal pathology over the said region. Leviteracetam was continued. Chest xray done also revealed no active infiltrates or lesion, hence AFB smear was deferred.

7-9th HD:

Patient tested for Toxoplasma and was noted to be IgM negative and IgG positive. TPH was noted to be positive up to 1:1280 dilutions. Patient was the treated for Toxoplasma and syphilis infection. CD4 and CD8 counts were requested. Dexamathasone was reduced to 5mg IV Q12. Antibiotics started were Ceftriaxone 2gm IV Q12, Metronidazole 500mg IV Q6, and SMX TMP 800/60 BID to be completed for 4 weeks. Patient was referred to the ophthalmology service for fundoscopy regarding CMV retinitis and toxoplasma retinitis but family opted to have the tests done as outpatient.

Rehabilitation therapy was also started. Patient was also referred to CNMS for nutritional build-up of the patient.

10th HD:

Patient was noted with whitish plaques on the oral mucosa and was started on Fluconazole 150mg TID. Repeat CT scan with contrast was also requested. Dexamethasone was also shifted to Dexamethasone 4mg/tab BID. Patient was cleared for possible discharge.

12th HD:

CD4 count revealed a value of only 49 and CD8 count at 422. Patient’s partner was also advised HIV screening as well. During patient’s course of admission, patient completed 10 days of ceftriaxone and metronidazole. Patient was cleared for possible discharge. IDS take home meds included TMX SMP 800/160mg 1 tab BID to complete for 1 month, Azithromycin 500mg/tab 2 ½ tab once a week, and Isoniazid 400mg/ tab OD x

6months. Patient was advised follow up. Nuero home meds included Leviteracetam 500mg BOD and gabapentin 75mg OD. Patient was then discharged stable and improved.

Laboratory Results

4/3/5(done outside)

4/4/15 4/5/15 4/6/15 4/7/15 4/8/15 4/11/15

Hgb 105 107Hct 21 30WBC 4.7 5.29Neutrophil 70 62Lymphocyte 13 16Platelet 198 197PBS Normocytic

hypochromic

Creatinine 60 53BUN 3.9ASL 25

Na 133K 4

FBS 75.6Cholesterol/Triglyceride/HDL/LDL

102.6/140.8/ 26.6/57

TSH 2.51FT3 4.81FT4 12.9

ANA 0.953ESR 66.0

RPR with titer Reactive 1:1 dilution

Cryptococcal Antigen Latex Agglutination

Negative

T. pallidum Heme agglutination

Positive up to 1:128 dilution

Toxoplasma IgM 0.735 Negative

Toxoplasma IgM 1.819Positive

PPD Negative

CD4 (%) 7.79CD4/ mm3 49CD8 (%) 67.01CD8/ mm3 422CD4/ CD8 0.1

Urinalysis (4/3/15)pH 6.0 Specific gravity 1.005 Protein Negative Glucose Negative WBC 3-6 RBC 0-2 Bacteria +3 Epithelial cells FewFecalysis (4/3/15)+ bacteria, No parasite seen, Negative occult blood

Imaging

Cervical MRI (4/1/15)Mild cervical canal stenosis with mild cord compression at levels C4-C5. Mild broad based disc bulge C6-7.CXR (4/7/15)Lungs are clear. Normal heart, diaphragm, sulci, and bony thorax.EEG (4/6/15)Abnormal EEG due to intermittent slowing of background activity ober both frontal region suggestive of focal pathology.Cranial MRI (4/6/15)No evidence of acute infarct. Multiple signals scattered in the cortical regions, some larger lesions with corresponding rim-enhancement. The largest lesion in the right parietal lobe is associated with moderate to severe vasogenic edema with resultant mild compression of the right lateral ventricle and 3mm, right to left subfalcine herniation. Considerations include infectious process and metastasis.