Download HISTORY TAKING AND PHYSICAL EXAMINATION

MEDICAL
GRANDROUNDS
Marion Priscilla B. Aurellado, M.D.
May 22, 2008
Objectives



To present a case of cerebral toxoplasmosis
To discuss an approach to right upper extremity
weakness in a young, previously healthy patient
with mass lesions in the brain on imaging
To present some epidemiologic data on the
burden of HIV/AIDS in the Philippines
Identifying Data






J.E.
27 year old male
Single
Filipino
Roman Catholic
From Pangasinan
Chief Complaint

Near syncopal attack
History of Present Illness

3 months



Intermittent dizziness
Light headedness
No meds/consult
History of Present Illness

2 weeks








RUE weakness
Weak hand grip
Orthopedic consult done
Unrecalled meds given
Advised observation
Progression of right
weakness
Follow-up consult done
EMG-NCV advised, but not
done
History of Present Illness

2 days

generalized body
weakness

Admission

Near syncopal attack
Clinic consult done
Hypotensive at 80/60
Advised admission



Review of Systems







(+) weight loss ~ 30
lbs in 4 months
(+) undocumented
intermittent fever &
chills since 4 months
(+) anorexia
(+) hair loss
(-) headache
(-) loss of consciousness
(-) cough or colds










(-) chest pain
(-) dyspnea
(-) palpitations
(-) abdominal pain
(-) nausea or vomiting
(-) LBM/constipation
(-) melena
(-) hematochezia
(-) dysuria
(-) hematuria
Past Medical History






No asthma
No DM
No history of hepatitis
No previous hospitalizations
No history of blood transfusions
No known food or drug allergies
Family History

(+) DM
Social History



Non-smoker
Occasional alcoholic beverage drinker
No illicit drug use
Physical Examination



General Survey:
Conscious, coherent, not in respiratory distress
Vital Signs:
BP lying: 100/60 BP sitting: 100/60
BP standing: 80/50 CR 88 RR 18 afebrile
HEENT:
Pink palpebral conjunctivae, anicteric sclerae, (-)
tonsillopharyngeal congestion, (-) cervical
lymphadenopathies
Physical Examination



Chest & Lungs:
Symmetric chest expansion, clear breath sounds
CVS:
Adynamic precordium, normal rate, regular
rhythm, no murmurs
Abdomen:
Flat abdomen, normoactive bowel sounds, no
tenderness, no organomegaly
Physical Examination

Extremities:
Full and equal pulses, no edema, (+) purplish
skin rash all over, (+) atrophy of dorsal
interossei muscles of right hand (claw hand
appearance), (+) subcutaneous nodules in all
extremities
Neurologic Examination

Mental Status Exam:
awake, oriented to 3 spheres
no memory lapses, good attention
intact repetition, recall 3/3
no aphasia, no R-L disorientation
Neurologic Examination

Cranial Nerves:
CN I - intact
CN II – pupils 3-4 mm EBRTL, visual fields intact
CN III, IV, VI – primary gaze midline, full EOMs
CN V – intact V1-V3
CN VII – no facial asymmetry
CN VIII - intact
CN IX, X – intact gag
CN XI – good SCM tone
CN XII – tongue midline
Neurologic Examination


Sensory: Intact to all modalities
Motor: 5/5 on both lower extremities and LUE
RUE: 5-/5 shoulder abduction
4/5 shoulder adduction
4/5 Shoulder extension
5-/5 shoulder flexion
5-/5 elbow flexion
4/5 elbow extension
Neurologic Examination
Cerebellum: No dysdiadochoinesia, no
dysmetria, able to walk in tandem, walk on
heels and toes
 Deep Tendon Reflexes: +2 left; +3 right
upper extremity, +2 right lower extremity
 Pathologic Reflexes: no Babinski
 Meninges: no nuchal rigidity

Salient Features








27 year old male
Previously healthy
Right upper extremity weakness, dizziness
Significant weight loss & anorexia
Intermittent fever
Generalized skin rash
Atrophy of dorsal interossei muscles of right hand
(claw hand appearance)
Subcutaneous nodules in all extremities
Where is the Lesion?

Focal peripheral nerve involvement
What is the Nature of the
Lesion?
Metabolic
 Inflammatory
 Trauma

Thomas PK, Ochoa J. Symptomatology and differential diagnosis of peripheral neuropathy. In:
Dyck PJ, Thomas PK, eds. Peripheral neuropathy. Philadelphia: Saunders, 1993:749-74.
Admitting Impression

Connective Tissue Disease
Course in the Wards





12 L ECG
Stat 5
IV Fluids started
ESR and ANA
EMG-NCV
st
1





Hospital Day
BP stable 100-110/60-70
No dizziness
(+) R arm weakness
ESR 120
Impression: Connective tissue disease
nd
2
Hospital Day

Prednisone started
EMG NCV R arm - NORMAL
ANA negative

Impression: Connective tissue disease ruled out


nd
2

Repeat CBC





Hospital Day
Anemia & eosinophilia
Fecalysis
Dermatology referral: Skin biopsy
Impression: Parasitic infection
MRI & MRA with Gadolinium
Salient Features

Subcutaneous nodules in all extremities
Anemia, eosinophilia
Multiple ring enhancing lesions on cranial MRI

Impression:


T/C Neurocysticercosis
R/O CNS Malignancy
Multiple Ring Enhancing Lesions on MRI
Neoplastic
Primary
Infectious
Metastatic
Multiple Ring Enhancing Lesions on MRI
Neoplastic
Infectious
Bacterial Tuberculoma
Abscess
Cryptococcus
Neurocysticercosis
Toxoplasmosis
Primary CNS Lymphoma

Present with one of 3 syndromes
 Subacute
progression of focal neurologic deficit
 Seizure
 Nonfocal
neurologic deficit: Headache
Fever, malaise, weight loss, anorexia suggest
metastatic more than primary
 Uniformly enhancing mass lesion in
immunocompetent
 Ring enhancing in the immunocompromised


Metastatic Brain Tumors

Most commonly originates from:
 Lung
CA
 Breast CA
 GI malignancy
 Melanoma

Bacterial Brain Abscess





Cause: Streptococcus (40%), Anaerobes, Staphylococcus
(10%)
Associated with otitis, mastoiditis, dental infections or
head trauma
Headache is the most common symptom in >75% of
cases
Classic triad of headache, fever, and focal neurologic
deficit
Multiple  hematogenous  poorly encapsulated

Tuberculoma
Uncommon manifestation of CNS tuberculosis
 Cause: Mycobacterium tuberculosis
 Transmission: Hematogenous spread from a
primary pulmonary or postprimary pulmonary
disease
 Seizures or focal neurologic deficits
 Diagnosis: AFB on CSF


Neurocysticercosis
Cause: Taenia solium
 Transmission: Ingestion of undercooked pork
 Cysticerci found anywhere in the body but are
commonly in:

 Brain
 CSF
 Skeletal
muscle
 Subcutaneous tissue
 Eye
Neurocysticercosis
Often presents with seizures and signs of
increased intracranial pressure
 Diagnosis:
 Fecalysis
 Neuroimaging
 Evidence of cysticercosis outside the CNS


Cryptococcosis
Cause: Cryptococcus neoformans
 Transmission: inhalation of yeast from the
environment (bird droppings)
 Risk factor: CD4 < 100
 Presents with headache, fever, cranial nerve
paresis, and meningeal irritation
 Diagnosis: India ink stain, CALAS


Toxoplasmosis




Cause: Toxoplasma gondii
Transmission: Ingestion of faecally
contaminated material, Ingestion of
undercooked meat
Risk factor: CD4 < 100
Asymptomatic in immunocompetent people
Toxoplasmosis

In immunocompromised, mainly involve the
CNS
Altered mental status (75%)
 Focal neurologic deficits (60%)
 Headaches (56%)
 Seizures (33%)


Diagnosis:

Serology: IgG and IgM
rd
3


Hospital Day
Mannitol started
Lumbar puncture done
Opening pressure 120 cmH2O
 Clear
 WBC 2 Lymphocytes 2 RBC 0
 Sugar 64 (nv 40-75); Protein 47.4 (15-45)
 No organisms or pus cells
 Negative for AFB, India Ink, KOH, CALAS


Dexamethasone started
th
4





Hospital Day
X-ray of the left femur – NORMAL
Infectious Diseases referral
History of unprotected sex with multiple sexual
partners and bisexual contacts
HIV screening
Whole abdomen UTZ – NORMAL
Multiple Ring Enhancing Lesions on MRI
Neoplastic
Primary
Infectious
Metastatic
Multiple Ring Enhancing Lesions on MRI
Neoplastic
Infectious
Bacterial Tuberculoma
Abscess
Cryptococcus
Neurocysticercosis
Toxoplasmosis
th
8




Hospital Day
CD4 count
Serum CALAS
Toxoplasma IgG
Toxoplasma IgM
th
9





Hospital Day
Discharged, awaiting final report:
Serum CALAS
Toxoplasma IgG
Toxoplasma IgM
CD4 titers and HIV test
Patient Outcome




HIV (+); CD4 = 53
Toxoplasma IgG 3.8 (nv <2)
Toxoplasma IgM 0.34 (nv <0.5)
Serum CALAS NEGATIVE
Clinical Correlation
Toxoplasmosis
Patient JE
Nonfocal to focal
neurologic deficits
Meningeal involvement
uncommon
CSF often unremarkable,
may have modest increase in
cell count & protein but
normal glucose
CD4 < 100
Motor deficit (RUE)
Absence of meningismus
Sugar 64 (nv 40-75); Protein
47.4 (15-45)
CD4: 53
Clinical Correlation
Toxoplasmosis
Patient JE
(+) IgG titers detected as
early as 2-3 weeks after
infection
Multiple discrete high signal
foci, heterogenous w/ wellcircumscribed margins, and
hyperintense on post
contrast MRI
Toxoplasma IgG 3.8 (<2)
Toxoplasma IgM normal
Multiple ring enhancing
lesions with vasogenic
edema in both cerebral
hemispheres at the
corticomedullary margin
Final Diagnosis



Cerebral Toxoplasmosis
HIV infection
Atopic Dermatitis
Management


Toxoplasmosis is rapidly fatal if untreated
Treatment of choice:
 Pyrimethamine plus folinic acid plus sulfadiazine
 Pyrimethamine plus folinic acid plus clindamycin
Danneman et al. Ann Intern Med 1992; 116:33-43.
6 weeks therapy at least, or until 3 weeks after
complete scan resolution
 Corticosteroids for raised intracranial pressure

Cohn et al. Am J Med 1989; 86: 521-7
Management


Oral co-trimoxazole is effective in doses of 2
tablets 4 times daily for 1 month followed by 2
tablets twice daily as secondary prophylaxis for
life
Lifetime prophylactic therapy for toxoplasmosis
would only apply if patients are not receiving
antiretroviral therapy with the CD4 count being
under 200 cells/μl
P Francis, January 2004, Vol. 94, No. 1 S Afr Med J
HIV Ab Seropositives by Year
HIV/AIDS Registry, January 1984-July 2007
(N=2,916
HIV Ab Seropositives by Gender and Age Group
HIV/AIDS Registry, January 1984-July 2007
(N=2,916)
Reported Modes of Transmission
HIV/AIDS Registry, January 1984-July 2007
(N=2,916)
Mode
Jan 84 -July 07
July 07
Heterosexual
Contact
1781
10
Homosexual Contact 567
9
Bisexual Contact
200
9
Blood/Blood
product
19
0
IV drug use
7
0
Reported Modes of Transmission
HIV/AIDS Registry, January 1984-July 2007
(N=2,916)
Needle prick injuries
3
0
Perinatal
44
0
No exposure
reported
295
3
TOTAL
2916
31
Patient Outcome






Readmitted after 2 weeks for seizure
Started on Co-trimoxazole and ARTs
Discharged against medical advice
Went back to Pangasinan
Lost to follow-up
AMD notified by company physician that the
patient expired
Thank you!!!