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MEDICAL GRANDROUNDS

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

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MEDICAL GRANDROUNDS

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  1. MEDICAL GRANDROUNDS Marion Priscilla B. Aurellado, M.D. May 22, 2008

  2. 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

  3. Identifying Data • J.E. • 27 year old male • Single • Filipino • Roman Catholic • From Pangasinan

  4. Chief Complaint • Near syncopal attack

  5. 3 months Intermittent dizziness Light headedness No meds/consult History of Present Illness

  6. 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

  7. 2 days Admission generalized body weakness Near syncopal attack Clinic consult done Hypotensive at 80/60 Advised admission History of Present Illness

  8. (+) 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 Review of Systems

  9. 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

  10. Family History • (+) DM

  11. Social History • Non-smoker • Occasional alcoholic beverage drinker • No illicit drug use

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Where is the Lesion? • Focal peripheral nerve involvement

  21. 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.

  22. Admitting Impression • Connective Tissue Disease

  23. Course in the Wards • 12 L ECG • Stat 5 • IV Fluids started • ESR and ANA • EMG-NCV

  24. 1st Hospital Day • BP stable 100-110/60-70 • No dizziness • (+) R arm weakness • ESR 120 • Impression: Connective tissue disease

  25. 2nd Hospital Day • Prednisone started • EMG NCV R arm - NORMAL • ANA negative • Impression: Connective tissue disease ruled out

  26. 2nd Hospital Day • Repeat CBC • Anemia & eosinophilia • Fecalysis • Dermatology referral: Skin biopsy • Impression: Parasitic infection • MRI & MRA with Gadolinium

  27. Salient Features • Subcutaneous nodules in all extremities • Anemia, eosinophilia • Multiple ring enhancing lesions on cranial MRI • Impression: T/C Neurocysticercosis R/O CNS Malignancy

  28. Multiple Ring Enhancing Lesions on MRI Neoplastic Infectious Primary Metastatic

  29. Multiple Ring Enhancing Lesions on MRI Neoplastic Infectious Bacterial Abscess Tuberculoma Cryptococcus Toxoplasmosis Neurocysticercosis

  30. 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 

  31. Metastatic Brain Tumors • Most commonly originates from: • Lung CA • Breast CA • GI malignancy • Melanoma 

  32. 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 

  33. 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 

  34. 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

  35. Neurocysticercosis • Often presents with seizures and signs of increased intracranial pressure • Diagnosis: • Fecalysis • Neuroimaging • Evidence of cysticercosis outside the CNS 

  36. 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 

  37. Toxoplasmosis • Cause: Toxoplasma gondii • Transmission: Ingestion of faecally contaminated material, Ingestion of undercooked meat • Risk factor: CD4 < 100 • Asymptomatic in immunocompetent people

  38. Toxoplasmosis • In immunocompromised, mainly involve the CNS • Altered mental status (75%) • Focal neurologic deficits (60%) • Headaches (56%) • Seizures (33%) • Diagnosis: • Serology: IgG and IgM

  39. 3rd 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

  40. 4th 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

  41. Multiple Ring Enhancing Lesions on MRI Neoplastic Infectious Primary Metastatic

  42. Multiple Ring Enhancing Lesions on MRI Neoplastic Infectious Bacterial Abscess Tuberculoma Cryptococcus Toxoplasmosis Neurocysticercosis

  43. 8th Hospital Day • CD4 count • Serum CALAS • Toxoplasma IgG • Toxoplasma IgM

  44. 9th Hospital Day • Discharged, awaiting final report: • Serum CALAS • Toxoplasma IgG • Toxoplasma IgM • CD4 titers and HIV test

  45. Patient Outcome • HIV (+); CD4 = 53 • Toxoplasma IgG 3.8 (nv <2) • Toxoplasma IgM 0.34 (nv <0.5) • Serum CALAS NEGATIVE

  46. Clinical Correlation

  47. Clinical Correlation

  48. Final Diagnosis • Cerebral Toxoplasmosis • HIV infection • Atopic Dermatitis

  49. Management • Toxoplasmosis is rapidly fatal if untreated • Treatment of choice: • Pyrimethamine plus folinic acidplus 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

  50. 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

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