medical grandrounds
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MEDICAL MEDICAL GRANDROUNDSGRANDROUNDS
Marion Priscilla B. Aurellado, Marion Priscilla B. Aurellado, M.D.M.D.
May 22, 2008May 22, 2008
ObjectivesObjectives
To present a case of cerebral To present a case of cerebral toxoplasmosistoxoplasmosis
To discuss an approach to right upper To discuss an approach to right upper extremity weakness in a young, extremity weakness in a young, previously healthy patient with mass previously healthy patient with mass lesions in the brain on imaginglesions in the brain on imaging
To present some epidemiologic data To present some epidemiologic data on the burden of HIV/AIDS in the on the burden of HIV/AIDS in the PhilippinesPhilippines
Identifying DataIdentifying Data
J.E.J.E. 27 year old male27 year old male SingleSingle Filipino Filipino Roman CatholicRoman Catholic From PangasinanFrom Pangasinan
Chief ComplaintChief Complaint
Near syncopal attackNear syncopal attack
History of Present IllnessHistory of Present Illness 3 months3 months Intermittent dizzinessIntermittent dizziness
Light headednessLight headedness No meds/consultNo meds/consult
History of Present IllnessHistory of Present Illness 2 weeks 2 weeks RUE weaknessRUE weakness
Weak hand gripWeak hand grip Orthopedic consult Orthopedic consult
donedone Unrecalled meds givenUnrecalled meds given Advised observationAdvised observation Progression of right Progression of right
weaknessweakness Follow-up consult doneFollow-up consult done EMG-NCV advised, but EMG-NCV advised, but
not donenot done
History of Present IllnessHistory of Present Illness
2 days2 days
AdmissionAdmission
generalized body generalized body weaknessweakness
Near syncopal Near syncopal attackattack
Clinic consult doneClinic consult done Hypotensive at Hypotensive at
80/6080/60 Advised admissionAdvised admission
Review of SystemsReview of Systems (+) weight loss ~ 30 (+) weight loss ~ 30
lbs in 4 monthslbs in 4 months (+) undocumented (+) undocumented
intermittent fever & intermittent fever & chills since 4 chills since 4 monthsmonths
(+) anorexia(+) anorexia (+) hair loss(+) hair loss (-) headache(-) headache (-) loss of (-) loss of
consciousnessconsciousness (-) cough or colds(-) cough or colds
(-) chest pain(-) chest pain (-) dyspnea(-) dyspnea (-) palpitations(-) palpitations (-) abdominal pain(-) abdominal pain (-) nausea or (-) nausea or
vomitingvomiting (-) LBM/constipation(-) LBM/constipation (-) melena(-) melena (-) hematochezia(-) hematochezia (-) dysuria(-) dysuria (-) hematuria(-) hematuria
Past Medical HistoryPast Medical History
No asthmaNo asthma No DMNo DM No history of hepatitisNo history of hepatitis No previous hospitalizations No previous hospitalizations No history of blood transfusionsNo history of blood transfusions No known food or drug allergiesNo known food or drug allergies
Family HistoryFamily History
(+) DM(+) DM
Social HistorySocial History
Non-smokerNon-smoker Occasional alcoholic beverage Occasional alcoholic beverage
drinkerdrinker No illicit drug useNo illicit drug use
Physical ExaminationPhysical Examination General Survey: General Survey:
Conscious, coherent, not in respiratory Conscious, coherent, not in respiratory distressdistress
Vital Signs:Vital Signs:BP lying: 100/60 BP sitting: 100/60 BP lying: 100/60 BP sitting: 100/60 BP standing: 80/50BP standing: 80/50 CR 88 RR 18 CR 88 RR 18 afebrileafebrile
HEENT:HEENT:Pink palpebral conjunctivae, anicteric Pink palpebral conjunctivae, anicteric sclerae, (-) tonsillopharyngeal congestion, sclerae, (-) tonsillopharyngeal congestion, (-) cervical lymphadenopathies(-) cervical lymphadenopathies
Physical ExaminationPhysical Examination Chest & Lungs:Chest & Lungs:
Symmetric chest expansion, clear Symmetric chest expansion, clear breath soundsbreath sounds
CVS:CVS:Adynamic precordium, normal rate, Adynamic precordium, normal rate, regular rhythm, no murmursregular rhythm, no murmurs
Abdomen:Abdomen:Flat abdomen, normoactive bowel Flat abdomen, normoactive bowel sounds, no tenderness, no sounds, no tenderness, no organomegalyorganomegaly
Physical ExaminationPhysical Examination
Extremities:Extremities:
Full and equal pulses, no edema, Full and equal pulses, no edema, (+) (+) purplish skin rash all over, (+) purplish skin rash all over, (+) atrophy of dorsal interossei muscles atrophy of dorsal interossei muscles of right hand (claw hand of right hand (claw hand appearance), (+) subcutaneous appearance), (+) subcutaneous nodules in all extremitiesnodules in all extremities
Neurologic ExaminationNeurologic Examination Mental Status ExamMental Status Exam::
awake, oriented to 3 spheresawake, oriented to 3 spheresno memory lapses, good attentionno memory lapses, good attentionintact repetition, recall 3/3intact repetition, recall 3/3no aphasia, no R-L disorientationno aphasia, no R-L disorientation
Neurologic ExaminationNeurologic Examination Cranial NervesCranial Nerves::
CN I - intactCN I - intactCN II – pupils 3-4 mm EBRTL, visual CN II – pupils 3-4 mm EBRTL, visual
fields intactfields intactCN III, IV, VI – primary gaze midline, CN III, IV, VI – primary gaze midline,
full EOMsfull EOMsCN V – intact V1-V3CN V – intact V1-V3CN VII – no facial asymmetryCN VII – no facial asymmetryCN VIII - intactCN VIII - intactCN IX, X – intact gagCN IX, X – intact gagCN XI – good SCM toneCN XI – good SCM toneCN XII – tongue midlineCN XII – tongue midline
Neurologic ExaminationNeurologic Examination
SensorySensory: Intact to all modalities: Intact to all modalities Motor:Motor: 5/5 on both lower extremities 5/5 on both lower extremities
and LUEand LUE
RUE: RUE: 5-/5 shoulder abduction5-/5 shoulder abduction4/5 shoulder adduction4/5 shoulder adduction4/5 Shoulder extension4/5 Shoulder extension5-/5 shoulder flexion5-/5 shoulder flexion5-/5 elbow flexion5-/5 elbow flexion4/5 elbow extension4/5 elbow extension
Neurologic ExaminationNeurologic Examination
CerebellumCerebellum: No dysdiadochoinesia, : No dysdiadochoinesia, no dysmetria, able to walk in no dysmetria, able to walk in tandem, walk on heels and toestandem, walk on heels and toes
Deep Tendon ReflexesDeep Tendon Reflexes: +2 left; : +2 left; +3 +3 right upper extremityright upper extremity, +2 right , +2 right lower extremitylower extremity
Pathologic ReflexesPathologic Reflexes: no Babinski: no Babinski MeningesMeninges: no nuchal rigidity: no nuchal rigidity
Salient FeaturesSalient Features 27 year old male27 year old male Previously healthyPreviously healthy Right upper extremity weakness, Right upper extremity weakness,
dizzinessdizziness Significant weight loss & anorexiaSignificant weight loss & anorexia Intermittent feverIntermittent fever Generalized skin rashGeneralized skin rash Atrophy of dorsal interossei muscles of Atrophy of dorsal interossei muscles of
right hand (claw hand appearance)right hand (claw hand appearance) Subcutaneous nodules in all extremitiesSubcutaneous nodules in all extremities
Where is the Lesion?Where is the Lesion?
Focal peripheral nerve involvementFocal peripheral nerve involvement
What is the Nature of the What is the Nature of the Lesion?Lesion?
MetabolicMetabolic InflammatoryInflammatory TraumaTrauma
Thomas PK, Ochoa J. Symptomatology and differential Thomas PK, Ochoa J. Symptomatology and differential diagnosis of peripheral neuropathy. In: Dyck PJ, Thomas diagnosis of peripheral neuropathy. In: Dyck PJ, Thomas PK, eds. Peripheral neuropathy. Philadelphia: Saunders, PK, eds. Peripheral neuropathy. Philadelphia: Saunders,
1993:749-74. 1993:749-74.
Admitting ImpressionAdmitting Impression
Connective Tissue DiseaseConnective Tissue Disease
Course in the WardsCourse in the Wards
12 L ECG 12 L ECG Stat 5Stat 5 IV Fluids startedIV Fluids started ESR and ANAESR and ANA EMG-NCVEMG-NCV
11stst Hospital Day Hospital Day
BP stable 100-110/60-70BP stable 100-110/60-70 No dizzinessNo dizziness (+) R arm weakness(+) R arm weakness ESR 120ESR 120 ImpressionImpression: Connective tissue : Connective tissue
disease disease
22ndnd Hospital Day Hospital Day
Prednisone startedPrednisone started EMG NCV R arm - NORMALEMG NCV R arm - NORMAL ANA negativeANA negative
ImpressionImpression: Connective tissue : Connective tissue disease ruled outdisease ruled out
22ndnd Hospital Day Hospital Day
Repeat CBCRepeat CBC Anemia & eosinophiliaAnemia & eosinophilia
Fecalysis Fecalysis Dermatology referral: Skin biopsyDermatology referral: Skin biopsy ImpressionImpression: Parasitic infection: Parasitic infection MRI & MRA with GadoliniumMRI & MRA with Gadolinium
Salient FeaturesSalient Features
Subcutaneous nodules in all Subcutaneous nodules in all extremitiesextremities
Anemia, eosinophiliaAnemia, eosinophilia Multiple ring enhancing lesions on Multiple ring enhancing lesions on
cranial MRIcranial MRI
ImpressionImpression: : T/C NeurocysticercosisT/C Neurocysticercosis
R/O CNS MalignancyR/O CNS Malignancy
Multiple Ring Enhancing Lesions on MRI
InfectiousNeoplastic
Primary Metastatic
Multiple Ring Enhancing Lesions on MRI
InfectiousNeoplastic
Bacterial Abscess
Tuberculoma
Neurocysticercosis
ToxoplasmosisCryptococcus
Primary CNS LymphomaPrimary CNS Lymphoma Present with one of 3 syndromesPresent with one of 3 syndromes
Subacute progression of focal neurologic Subacute progression of focal neurologic deficitdeficit
SeizureSeizure Nonfocal neurologic deficit: HeadacheNonfocal neurologic deficit: Headache
Fever, malaise, weight loss, anorexia Fever, malaise, weight loss, anorexia suggest metastatic more than primarysuggest metastatic more than primary
Uniformly enhancing mass lesion in Uniformly enhancing mass lesion in immunocompetentimmunocompetent
Ring enhancing in the Ring enhancing in the immunocompromisedimmunocompromised
Metastatic Brain TumorsMetastatic Brain Tumors
Most commonly originates from:Most commonly originates from: Lung CALung CA Breast CABreast CA GI malignancyGI malignancy Melanoma Melanoma
Bacterial Brain Abscess
Cause: Cause: StreptococcusStreptococcus (40%) (40%), , Anaerobes, Anaerobes, Staphylococcus Staphylococcus (10%)(10%)
Associated with otitis, mastoiditis, dental Associated with otitis, mastoiditis, dental infections or head traumainfections or head trauma
Headache is the most common symptom Headache is the most common symptom in >75% of casesin >75% of cases
Classic triad of headache, fever, and focal Classic triad of headache, fever, and focal neurologic deficitneurologic deficit
Multiple Multiple hematogenous hematogenous poorly poorly encapsulatedencapsulated
TuberculomaTuberculoma
Uncommon manifestation of CNS Uncommon manifestation of CNS tuberculosistuberculosis
Cause: Cause: Mycobacterium tuberculosisMycobacterium tuberculosis Transmission: Hematogenous spread Transmission: Hematogenous spread
from a primary pulmonary or from a primary pulmonary or postprimary pulmonary diseasepostprimary pulmonary disease
Seizures or focal neurologic deficitsSeizures or focal neurologic deficits Diagnosis: AFB on CSFDiagnosis: AFB on CSF
NeurocysticercosisNeurocysticercosis
Cause: Cause: Taenia soliumTaenia solium Transmission: Ingestion of Transmission: Ingestion of
undercooked porkundercooked pork Cysticerci found anywhere in the body Cysticerci found anywhere in the body
but are commonly in:but are commonly in: BrainBrain CSFCSF Skeletal muscleSkeletal muscle Subcutaneous tissueSubcutaneous tissue EyeEye
NeurocysticercosisNeurocysticercosis
Often presents with seizures and Often presents with seizures and signs of increased intracranial signs of increased intracranial pressurepressure
Diagnosis:Diagnosis:FecalysisFecalysisNeuroimaging Neuroimaging Evidence of cysticercosis outside Evidence of cysticercosis outside
the CNSthe CNS
CryptococcosisCryptococcosis
Cause: Cause: Cryptococcus neoformansCryptococcus neoformans Transmission: 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
ToxoplasmosisToxoplasmosis
Cause: Cause: Toxoplasma gondiiToxoplasma gondii Transmission: Transmission: Ingestion of faecally c Ingestion of faecally c
ontaminated material ontaminated material, , Ingestion of u Ingestion of u ndercooked meat ndercooked meat
Risk factor: CD4 < 100Risk factor: CD4 < 100 Asymptomatic in immunocAsymptomatic in immunocompetent ompetent
peoplepeople
ToxoplasmosisToxoplasmosis
In immunocompromised, mainly In immunocompromised, mainly involve the CNSinvolve the CNS Altered mental status (75%)Altered mental status (75%) Focal neurologic deficits (60%)Focal neurologic deficits (60%) Headaches (56%)Headaches (56%) Seizures (33%)Seizures (33%)
Diagnosis:Diagnosis: Serology: IgG and IgMSerology: IgG and IgM
33rdrd Hospital Day Hospital Day
Mannitol startedMannitol started Lumbar puncture doneLumbar puncture done
Opening pressure 120 cmH2OOpening pressure 120 cmH2O ClearClear WBC 2 Lymphocytes 2 RBC 0WBC 2 Lymphocytes 2 RBC 0 Sugar 64 (nv 40-75); Protein 47.4 (15-45)Sugar 64 (nv 40-75); Protein 47.4 (15-45) No organisms or pus cellsNo organisms or pus cells Negative for AFB, India Ink, KOH, Negative for AFB, India Ink, KOH,
CALASCALAS Dexamethasone startedDexamethasone started
44thth Hospital Day Hospital Day
X-ray of the left femur – NORMALX-ray of the left femur – NORMAL Infectious Diseases referralInfectious Diseases referral History of unprotected sex with History of unprotected sex with
multiple sexual partners and multiple sexual partners and bisexual contactsbisexual contacts
HIV screeningHIV screening Whole abdomen UTZ – NORMALWhole abdomen UTZ – NORMAL
Multiple Ring Enhancing Lesions on MRI
InfectiousNeoplastic
Primary Metastatic
Multiple Ring Enhancing Lesions on MRI
InfectiousNeoplastic
Bacterial Abscess
Tuberculoma
Neurocysticercosis
ToxoplasmosisCryptococcus
88thth Hospital Day Hospital Day
CD4 countCD4 count Serum CALAS Serum CALAS Toxoplasma IgG Toxoplasma IgG Toxoplasma IgMToxoplasma IgM
99thth Hospital Day Hospital Day
Discharged, awaiting final report:Discharged, awaiting final report: Serum CALAS Serum CALAS Toxoplasma IgG Toxoplasma IgG Toxoplasma IgMToxoplasma IgM CD4 titers and HIV testCD4 titers and HIV test
Patient OutcomePatient Outcome
HIV (+); CD4 = 53HIV (+); CD4 = 53 Toxoplasma IgG 3.8 (nv <2)Toxoplasma IgG 3.8 (nv <2) Toxoplasma IgM 0.34 (nv <0.5)Toxoplasma IgM 0.34 (nv <0.5) Serum CALAS NEGATIVESerum CALAS NEGATIVE
Clinical CorrelationClinical CorrelationToxoplasmosisToxoplasmosis Patient JEPatient JE
Nonfocal to focal Nonfocal to focal neurologic deficitsneurologic deficits
Motor deficit (RUE)Motor deficit (RUE)
Meningeal Meningeal involvement involvement uncommonuncommon
Absence of Absence of meningismusmeningismus
CSF often CSF often unremarkable, may unremarkable, may have modest increase have modest increase in cell count & in cell count & protein but normal protein but normal glucoseglucose
Sugar 64 (nv 40-75); Sugar 64 (nv 40-75); Protein 47.4 (15-45)Protein 47.4 (15-45)
CD4 < 100CD4 < 100 CD4: 53CD4: 53
Clinical CorrelationClinical Correlation
ToxoplasmosisToxoplasmosis Patient JEPatient JE
(+) IgG titers (+) IgG titers detected as early as detected as early as 2-3 weeks after 2-3 weeks after infectioninfection
Toxoplasma IgG 3.8 Toxoplasma IgG 3.8 (<2)(<2)
Toxoplasma IgM Toxoplasma IgM normalnormal
Multiple discrete Multiple discrete high signal foci, high signal foci, heterogenous w/ heterogenous w/ well-circumscribed well-circumscribed margins, and margins, and hyperintense on post hyperintense on post contrast MRIcontrast MRI
Multiple ring Multiple ring enhancing lesions enhancing lesions with vasogenic with vasogenic edema in both edema in both cerebral hemispheres cerebral hemispheres at the at the corticomedullary corticomedullary marginmargin
Final DiagnosisFinal Diagnosis
Cerebral ToxoplasmosisCerebral Toxoplasmosis HIV infectionHIV infection Atopic DermatitisAtopic Dermatitis
ManagementManagement Toxoplasmosis is rapidly fatal if untreatedToxoplasmosis is rapidly fatal if untreated Treatment of choice:Treatment of choice:
PyrimethaminePyrimethamine plus plus folinic acid folinic acid plus plus sulfadiazisulfadiazinene
PyrimethaminePyrimethamine plus plus folinic acid folinic acid plus plus clindamycclindamycinin
1992Danneman et al. Ann Intern Med ; 1992Danneman et al. Ann Intern Med ;1116316333-43.-43. 6 weeks therapy at least, or until 3 weeks after 6 weeks therapy at least, or until 3 weeks after
complete scan resolution complete scan resolution Corticosteroids for raised intracranial pressure Corticosteroids for raised intracranial pressure
-1989 86 5217Cohn et al. Am J Med ; : -1989 86 5217Cohn et al. Am J Med ; :
ManagementManagement
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 YearHIV Ab Seropositives by YearHIV/AIDS Registry, January 1984-July HIV/AIDS Registry, January 1984-July
2007 (N=2,9162007 (N=2,916
HIV Ab Seropositives by Gender and HIV Ab Seropositives by Gender and Age GroupAge Group
HIV/AIDS Registry, January 1984-July HIV/AIDS Registry, January 1984-July
2007 (N=2,916)2007 (N=2,916)
Reported Modes of TransmissionReported Modes of TransmissionHIV/AIDS Registry, January 1984-July HIV/AIDS Registry, January 1984-July
2007 (N=2,916)2007 (N=2,916)
ModeMode Jan 84 -July 07Jan 84 -July 07 July 07July 07
Heterosexual Heterosexual ContactContact
17811781 1010
Homosexual Homosexual ContactContact
567567 99
Bisexual Bisexual ContactContact
200200 99
Blood/Blood Blood/Blood productproduct
1919 00
IV drug useIV drug use 77 00
Reported Modes of TransmissionReported Modes of TransmissionHIV/AIDS Registry, January 1984-July HIV/AIDS Registry, January 1984-July
2007 (N=2,916)2007 (N=2,916)
Needle prick Needle prick injuriesinjuries
33 00
PerinatalPerinatal 4444 00
No exposure No exposure reportedreported
295295 33
TOTALTOTAL 29162916 3131
Patient OutcomePatient Outcome
Readmitted after 2 weeks for seizureReadmitted after 2 weeks for seizure Started on Co-trimoxazole and ARTsStarted on Co-trimoxazole and ARTs Discharged against medical adviceDischarged against medical advice Went back to PangasinanWent back to Pangasinan Lost to follow-upLost to follow-up AMD notified by company physician AMD notified by company physician
that the patient expiredthat the patient expired
Thank you!!!Thank you!!!
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