CASE PROTOCOL

Objectives:
1)
2)

To present a case of
To discuss

This is a case of COV, 46/F from Tagytay City, Cavite married, Roman Catholic, working as a fitness instructor. She
was admitted in Manila Doctors Hospital on April 4, 2015.
Chief Complaint: Unsteady gait
The patient was allegedly well until
Three months PTA, noted weakness on the right arm described as inability to carry her child. No reported trauma.
Patient then sought consult at local hospital and work up done included cervical neck CT scan. Patient then claimed she was
diagnosed with brachial plexus palsy. Patient then underwent rehabilitation therapy for 3 sessions and reported improvement in
the grip strength.
One week PTA, patient then had light headedness associated with unsteady gait and tendency to fall. No reported weakness,
slurring of speech, or headache.
During the interim symptoms persisted.
Three days PTA, patient sought consult at Tagaytay Hospital and was then subsequently admitted and manged as a
case of CVD infarct. Patient claimed that the laboratory tests done yielded normal results. She was then advised cranial CT scan
hence 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 man
Fond of eating raw fish and sea food in the Philippines and at Mexico
Non smoker
Occasional alcohol beverage drinking; no known binge-drinking episodes; no known illicit drug use
Claimed 2 sexual partners (first (deceased) and second husbands)
Used to work in Africa 8 months and 10 years ago, and has frequent travels between Philippines and Mexico
Family History:
(+) T2DM - mother
(-) hypertension, (-)cerebrovascular accidents, (-)cardiac disease

ROS:
(-)fever

(-)behavioral changes

(-) anorexia

(-)chestpain

(+) Anorexia since last January with unqualified weight loss,

(ER Resident):
BP: 110/70

HR: 80

RR: 20

Temp: 36.8

Clear breath sounds, distinct heart sounds

GCS 15
Patient was then referred to IM
(ER IM ROD):
Physical Exam:
BP: 120/70

HR: 80

RR: 20

Temp: 36.5

GCS15
Non labored breathing, dizzy
Pink conjunctivae, anicteric sclera. (-)CLAD
No retractions, equal chest expansion; Clear breath sounds
Adynamic precordium, distinct heart sounds, no murmurs appreciated
Abdomen flat, normoactive bowel sounds, nontender, no evident masses palpable
No gross joint deformities; no gross skin lesions
Full and equal peripheral pulses; no edema
Skin warm, dry
Neurological Exam:
MSE:
Frontal: Awake, alert, coherent, intact speech
Parietal: No R-L disorientation, - finger agnosia, - Acalculia
Temporal: Intact recent, remote, and immediate memory, oriented to 3 spheres
Occipital: Able to recognize familiar objects
Cranial nerves
CNI: intact
CNII: both pupils 2mm briskly reactive to light, visual field intact, fundoscopy not done
CNIII, IV, VI: primary gaze at midline, full EOMs
CNV: intact V1-3, good masseter tone
CNVII: no facial asymmetry
CNVIII: intact gross hearing
CNIX, X: good gag, uvula at midline

CNXI: Good shoulder shrug and SCM tone

CNXII: tongue at midline
Motor: 5/5 on bilateral lower extremities, 2/5 on right upper, and 5/5 on left upper
Sensory: 100% on all extremities
DTR: 2+ on all
Cerebellar: No dysmetria, dysdiadokinesia
Posterior Column: unsteady gait, tendency to fall on either side, Romberg not done, unable to stand
Neck supple
(-) Babinski (-) Clonus
Laboratory tests done included CBC, BUN, creatinine, lipid profile, FBS, and SGPT. Electrolytes were done outside. Cranial MRI
with contrast and 12 lead ECG were done.
Initial impression: D7 Cerebellar infarct, R/O Cerebellar mass; brachial nerve palsy
Course of Admission:
1st Hospital Day:
Patient admitted at the floors managed as a case of cerebellar infarct. No reports of headache or slurring of speech
noted. Patient had stable vital signs but still presented with 2/5 muscle strength on right arm and 5/5 on rest of the extremities.
Intact sensation on all extremities was reported. Initially put in complete bed rest without bathroom privileges, and diet started
was 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 AP, cranial MRI was ordered 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.
A: D7 Cerebellar infarct, R/O Cerebellar mass; brachial nerve palsy
2nd HD:
Patient had one episode of twitching of the right upper extremity lasting for less than 3 minutes. No associated loss of
consciousness. After the seizure patient had stable VS. Patient was seen after the seizure, assessed as to be awake, and
oriented. Patient was noted to have shallow left nasolabial fold and tongue deviation to the left, unchanged 2/5 right hand
weakness. Vital signs remained to be stable. Patient was put into seizure precaution. Started on Leviteracetam 500mg/tab BID
and diazepam 5mg/IV PRN for frank seizure. Also, EEG was requested.
A: 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 AP the started the patient on Dexamethasone 5mg IV Q8 and Leviteracetam was continued. Patient was then referred
to The IDS service for co-management.
A: Intracranial mass probable sec to Opportunistic infection, R/O Herniation syndrome R/O HIV infection
4-5th HD
VS was stable and was in neuro status quo. IDS service requested for code 174 test and CXR, TPHA (quantitative),
Toxoplasma IgG and IgM, PPD were requested. Patient was also started on Ceftriaxone 2gm IV Q12 and Metronidazole 500mg
IV Q6.
A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4. Tuberculoma; R/O Herniation
syndrome
6th HD:
VS were stable and was in neuro status quo. EEG results showed intermittent slowing of background activity over
frontal region suggestive of focal pathology over the said region. Leviteracetam was continued. Chest xray revealed no active
infiltrates or lesion, hence AFB smear was deferred.
A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4. Tuberculoma; R/O Herniation
syndrome
7th HD:
VS was stable and was in neuro status quo. Patient tested for Toxoplasma IgM negative, IgG positive, and TPH was
positive up to 1:1280 dilutions. Patient was the treated for Toxoplasma infection and syphilis infection. Antibacterial on board
included Ceftriaxone 2gm IV Q12, Metronidazole 500mg IV Q6, and SMX TMP 800/60 BID to be completed for 4 weeks.
A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4. Tuberculoma; R/O Herniation
syndrome
8th HD:
VS was stable and was in neuro status quo. CALAS, CD4 and CD8 counts were requested. Dexamathasone was
reduced to 5mg IV Q12 and the rest of the antibacterial were continued. Rehabilitation therapy was also started.
9th HD:
VS was stable and was in neuro status quo. 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. CNMS was also on bard
for the nutritional build-up of the patient.
A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4. Tuberculoma; R/O Herniation
syndrome
10th HD:

VS was stable and was in neuro status quo. Patient presented with whitish plaques in the oral mucosa and was started on
Fluconazole 150mg TID. Repeat CT scan with contrast was also requested. Patient at this time was on her Day 8 of Ceftriazone,
Day 7 of Metronidazole and TXM SMP. Dexamethasone was also shifted to Dexamethasone 4mg/tab BID. Patient was cleared
for possible discharge. A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4.
Tuberculoma; R/O Herniation syndrome, Oral candediasis
12th HD:
VS was stable and was in neuro status quo. Initial CD4 count came out as 49 and CD8 count at 422. Patients partner
was advised code 174 workup. 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
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 apparently with improved conditions.