ADCON

PRESENTATION
Leandro Martin B. Mangubat
September 30, 2015

General Information
CN is a 38 year old, married, Roman Catholic female from Phase IV
Cembo Makati City
The patient was admitted on September 17, 2015 and the interview
was conducted on September 28, 2015 at the Female Medicine ward
in Ospital ng Makati The informant was the patient herself, who had
good reliability (80%)

Chief Complaint
Headache

History of Present Illness

I year PTA patient experienced on and off headache on the right
frontal area, non radiating, with a pain score of 5/10 and no particular
aggravating or relieving factors. The patient sought consult at the
Osmak IM OPD and was managed as Migraine with celecoxib and
Betahistine which provided some relief.
9 months PTA headaches recurred with associated decreased hearing
in the right ear. No consult was done, no medications were taken
2 months PTA on and off headaches and decreased hearing were still
present and the patient was noted to have right sided facial
asymmetry, which prompted consult in OPD and was managed as
Bells Palsy with Methylprednisolone for 1 month

History of Present Illness

1 month PTA aforementioned symptoms still occurred with
improvement of right sided facial asymmetry. The patient then noted
double vision pagduduling and sought consult at OPD where she
was referred to Ophthalmology and managed as right lateral rectus
palsy. MRI with contrast was requested
1 day PTA . MRI results revealed mastoiditis with adjacent
meningitis extending to the cavernous sinus with
enhancement of right cranial nerve VII-VIII complex. The
patient was then referred to Internal Medicine service and was
advised admission, hence admission

Physical Exam
Patient was conscious, coherent, ambulatory and not in cardiorespiratory
distress or pain
Patient was normotensive, non-tachypneic, non-tachycardic, and afebrile
Skin: warm, moist, good turgor, no generalized lesions
HEENT: Normocephalic, pink palpebral conjunctivae, anicteric sclera,
right eye deviates medially; no cervical lymphadenopathies, flat neck
veins, no tonsillopharyngeal congestion
Chest and Lungs : symmetrical chest expansion, vesicular breath sounds
Heart: Adynamic precordium, regular rate and rhythm, no murmurs
Abdomen: flabby, normoactive bowel sounds, soft, non-tender with no
palpable masses
Rectal: not done
Extremities: full and equal pulses, no cyanosis, no edema

 Neuro Exam
Cerebrum: Conscious coherent oriented to 3 spheres, obeys command, responds
to queries
Cerebellum: (-) Nystagmus, (-) dysdiadokinesia (-) dysmetria
Cranial nerves
CN I: can smell
CN II: 2-3 mm pupils equally reactive to light
CN III, IV, VI: impaired lateral deviation, right, intact other EOMs
CN V: intact V1, V2, V3, (+) corneal reflex,(+) masseter tone
VII: shallow nasolabial fold, right
VII: (+) gross hearing R<L
IX and X: Good Gag reflex
XI: Good Shoulder Shrug
XII: Tongue midline
Motor Strength Sensory DTRs
5/5 5/5 100 100 ++ ++
5/5 5/5 100 100 ++ ++
5/5 4/5 100 100 ++ ++
5/5 4/5 100 100 ++ ++
No nuchal Rigidity, (-) Kernigs sign, (-) Brudzinsky sign

Salient Features

S
38 year old Female
Chief complaint of Headache, on and off for 1 year duration
HPI: Previously managed migraine headache, bells palsy, right lateral rectus palsy, MRI showed
mastoiditis with adjacent meningitis extending to the cavernous sinus with
enhancement of right cranial nerve VII-VIII complex
Associated symptoms: nausea, dizziness, photophobia, no history of fever, no changes in
sensorium, no history seizures or convulsions
PMH: Maternal side history of stroke

O
Patient was conscious, coherent, ambulatory and not in cardiorespiratory distress or pain
right eye deviates medially
CN III, IV, VI: impaired lateral deviation, right, intact other EOMs
VII: shallow nasolabial fold, right
VII: (+) gross hearing R<L
No signs of meningeal irritation

Admitting Diagnosis
Chronic Meningitis, probably bacterial

Differential Diagnosis
TB meningitis
Rule in: endemic area, chronic in duration, focal neurological signs,
MRI findings
Rule out: with CSF culture
Temporal Bone tumor
Rule in: Chronic headache, focal neurological signs, no fever,
decreased hearing
Rule out: young age, CT scan of the temporal bone

Management

Diagnostic
CSF analysis - leukocytosis (>100 cells/uL) with neutrophilic predominance,
decreased glucose (<40 mg/dL) and/or CSF/serum glucose ratio (<0.4), increased
protein (>45 mg/dL), increased opening pressure (>180 mmH2O)* harrisons
Chest X-ray - PA
AFB sputum exam
CBC
Blood glucose analysis (RBS)
Temporal bone CT scan

Therapeutic
Empiric Treatment: broad-spectrum IV antibiotic with adjuvant corticosteroids
IV antibiotics depending on CSF culture in the case of meningitis
Surgical resection with adjuvant radiotherapy in the case of temporal bone tumor
Kochs medication in the case of TB meningitis (Treatment category IIa
2HRZE/10HR

In this case:

CSF analysis
Glucose: 58.74 mg/dL (60-80)
CSF/Serum glucose ratio: 0.48
Protein: 68.98 mg/dL (14-45)
WBC: 22 cells/ uL
Neutrophils: 22%
India Ink: negative

CBC
WBC: 14.2 (4-11)
Neutrophils: 75 (50-70)
Lymphocytes: 15 (20-40)
Monocytes: 9 (2-5)
Eosinophils: 1 (2-4)

Empiric antibiotic
Ceftriaxone 2g TIV Q12
Metronidazole 1g TIV as loading dose then 500g TIV Q6
Other medications
Paracetamol 500mg tab, 1 tablet every 4 hours for fever > 37.8c
Paracetamol 300mg TIV every for hours for headache and/or fever >37.8c