An interesting case of hemiparesis

Prof.Dr.G.Sundaramurthy’s unit

-Dr.K.Senthamizh selvan

CLINICAL SCENARIO• Venkatesan

• 40yrs /male

• kanchipuram

• manual labourer

Presenting complaints :

- weakness of left UL,LL

- slurring of speech for past 10

days

HISTORY OF PRESENT ILLNESS• H/O weakness of left UL and LL for the past

10 days ,insidious onset ,progressive in nature H/O difficulty in raising his arm H/O difficulty in buttoning his shirts H/O difficulty in climbing stairs H/O difficulty in holding his slippers • No H/O difficulty in turning side to side in

bed,or getting up from bed • No H/O diminished/altered perception of

clothes,hot & cold objects

• No H/O of unsteadiness or fall while washing his face

• No H/O involuntary movements

• No H/O disturbance in memory,emotional changes

• No H/O altered smell perception

• No H/O diminished visual perception

• No H/O double vision

• No H/O impaired sensation over face

• No H/O difficulty in mastication

• H/O of deviation of angle of mouth to R side associated with slurring of speech

• No H/O of hard of hearing ,tinnitus ,giddiness

• H/O difficulty in swallowing food , associated with nasal regurgitation

• No H/O of change in voice

• No H/O difficulty in turning head to opposite side or shrugging shoulders

• No H/O difficulty in moving the tongue

• No H/O bladder and bowel disturbance

• H/O headache ,diffuse ,dull in character ,not associated with blurring of vision ,vomiting ,no postural variation ,no aggravating and relieving factors.

• No H/O fever , seizures , recent head trauma

• No H/O chest pain,palpitation , breathlessness, syncope

PAST HISTORY Not a K/C SHT,DM,PT,CAHD,RHD,epileptic

PERSONAL HISTORY :

• Mixed diet

• occasional smoker and alcoholic

FAMILY HISTORY :

Not contributory

ON EXAMINATION • Conscious

• Responds to simple commands

• Emaciated

• Afebrile

• Hydration fair

• pallor+/icterus-/cyanosis-/clubbing-/PE-

• No SGLA

• Vitals : BP-110/70 mmHg

PR-88/min ,regular

-- Papulo-nodular skin lesions with excoriations seen over arm, fore arm,trunk,back,medial aspect of thigh----suggestive of extensive scabies ? NORWEGIAN

SYSTEM EXAMINATION

• CVS: S1,S2+

No Murmur

• RS: NVBS +

No added sounds

• P/A : soft

No HSM

BS+

CNS EXAMINATON

HIGHER MENTAL FUNCTION:

- conscious

- oriented

- memory intact

- no emotional disturbance

CRANIAL NERVES

NERVE RIGHT LEFT

1 N N

2 -Visual acuity,field of vision & fundus

N N

3,4,6 EOM pupils

Full4 mm,reacting

Full4 mm,reacting

5 N N

7 N UMN palsy

8 N N

9,10 Gag&uvular movements impaired

Gag&uvular movements impaired

11 N N

12 N Deviated to left side

MOTOR SYSTEM RIGHT LEFT

Bulk N N

Tone UL LL

NN

Increased

Power UL LL

5/55/5

2/52/5

DTR ++ +++

Superficial reflexes + -

Plantar Flexor Extensor

SENSORY SYSTEM : all modalities clinically

normal

CEREBELLUM: could not be tested

NO meningeal signs

spine and cranium : normal

Problems

• Left hemiparesis,left UMN facial palsy

• B/L LMN 9&10th weakness

• LEFT LMN 12th nerve weakness

• Extensive scabetic lesions ? NORWEGIAN

IMPRESSION :

-CVA with brain stem involvement

- Demyelinating disease

- Retroviral disease

INVESTIGATIONS CBC : TC – 9800 cells/cumm DC- 56/40/4 ESR-25mm/hr Hb- 9 gm/dl MCV-82fl MCHC-30g/dl Platelet count -1.2lakh/cummRFT: Blood sugar-134 mg/dl Blood urea-24.8mg/dl S.creatinine-0.9mg/dl

S.Electrolytes : Na+ 130 K+ 4.4 Cl- 98 HCO3 - 23LFT: T.Bilirubin-1.2 D.Bilirubin-0.4 SGOT/SGPT-44/36 SAP-120ECG- ---WNL

X-RAY

CT BRAIN -CONTRAST

FINDINGS

----Thin walled cystic lesions in L frontal and B/L parietal lobe

----Enhancement of wall with central necrosis

----Eccentric target sign +

• Sputum AFB : Negative

• Mantoux :negative • HIV ELISA: POSITIVE

• VDRL: Non reactive • USG abdomen –no HSM, no intra abdominal lymphadenopathy

• ECHO: No RWMA Normal LV systolic function

• CSF analysis :

cell count – 50cells/cumm

lymphocytic predominance

total protein -110mg /dl

glucose -44mg/dl

ADA –low titres

Cob web –absent

TOXOPLASMA SEROLOGY :

IgG antibody positive in hightitres>500IU/L.

IgM- 1wk to 1month ,rarely 1 year,

-Typically absent in reactivated disesae

IgG-1month , persists life long,

-In its absence infection is less likely

Problems • Rapidly progressing neurological signs;

• Multiple ring enhancing lesions in CT brain

• HIV-ELISA positivity

• Toxoplasma antibody positivity

Further approach to our patient

• Neurophysician opinion : -Retroviral disease -CNS toxoplasmosis -To consider the possibility of tuberculoma • Dermatologist opinion for extensive scabies : -T.ivermectin 200mic/kg - 5%permethrin lotion

• Pt was registered in ART centre ,GSH CD4 count :96 cells/cumm

TREATMENT GIVEN - Inj. Mannitol 175ml iv tds - Inj.Lasix 20mg iv bd - T.pyrimethamine 100mg/d loading dose,followed by 50mg/d - T.sulfadiazine 4g/d - T.folic acid 10mg/d - T.septran DS 1BD -supportive care -physiotherapy

-Patient improved symptomatically after 5 days

-He was discharged at his request,advised to review after 6 weeks

REPEAT CT AFTER 6 WEEKS

TOXOPLASMA Vs TUBERCULOMA

Favouring toxoplasma

• M C ring enhancing lesions

in HIV (50-70%)

• Toxoplasma serology +

• clinical response to treatment

• Rapid radiological clearance

Against tuberculoma

• No past H/O of PT,ATT

• Normal chest x-ray

• Normal USG abd

• Sputum AFB ,Mantoux -ve

• CSF :AFB –ve

absent cob web

ADA in low titres

• Rapid radiological clearance

FINAL DIAGNOSIS

RETRO VIRAL DISEASE

CEREBRAL TOXOPLASMOSIS NORWEGIAN SCABIES

• Pt was started on ART

• Along with maintenance dose of

T.pyrimethamine 25mg/d

T.sulfadiazine 2g/d

T.folic acid 10mg/d

T.septran DS 1od

• Referred to GHTM, Tambaram for further follow up ,as per his wish.

TOXOPLASMOSIS

• Toxoplasma gondii-protozoan parasite

• Definitive host-felines

• Intermediate host-humans ,mammals

• asymptomatic –in immuno competent

• symptomatic –AIDS,congenital toxoplasmosis

• Reactivation syndrome -10 times common in

pts with antibody to organism(underlying immune compromise reactivates latent infection)

Life cycle

Human infection

Humans enter life cycle of t.gondii

Ingesting meat infected with tissue cysts

Ingesting food contaminated with infectious oocyst(cat feces)

transplacental transmission

infected organ transplantation

blood transfusion

CLINICAL FEATURES

• In Immuno competent:

-asymptomatic

-symptomatic(fever,lymphadenopathy

non specific rash)

- rarely chorio-retinitis

CONGENITAL TOXOPLASMOSIS

Toxoplasmosis acquired

Immuno-competant Immuno-compromised

Prior to pregnancy No risk Moderate risk

During pregnancy Mild risk Maximum risk

• Infected babies -75%--no symptoms -15%--chorioretinitis -10% --CNS symptoms• Features : Fever Lymphadenopathy Encephalitis seizures Anemia Microcephaly Non specific skin rash.

IMMUNO COMPROMISED ADULTS usually present with:• head ache • fever • seizures• focal deficits• ataxia• cognitive dysfunction• neuro psychiatric manifestations• visual disturances

Unusual presentations :

-myocarditis

-pneumonitis

-disseminated toxoplasmosis

WORK UP

• Base line investigations

• Toxoplasma serology:

• SABIN –FELDMAN DYE TEST: -sensitive &specific neutralization test -detects IgG antibody• Detection of toxoplasma antigen in body

fluids by ELISA• IFA,IHA,Double sandwich IgM ELISA • PCR : - demonstrates genome in body fluids,

CSF,amniotic fluid,BAL. -40% sensitive in CSF.

• CSF analysis: -mild mono nuclear pleocytosis -increased protein -low glucose -IgG antibody • CT BRAIN –contrast Can show single lesion• MRI brain-more sensitive -multiple lesions ,MC sites basal

ganglia and cortico medullary junction -single lesion –suspect diagnosis

ECCENTRIC TARGET SIGN

• MR-spectroscopy

• Tissue diagnosis

TREATMENT

• Immuno compromised

• Immuno competant:

Asymptomatic , age <5

symptomatic

pregnancy

vital organ dysfunction

OP TREATMENT: - Immuno competent - ocular toxoplasmosisIP TREATMENT: -Immuno compromised -CNS toxoplasmosis -Toxoplasmic pneumonitis/myocarditis -Disseminated toxoplasmosis

TREATMENT OPTIONS :

for 6 wks

Drugs Initial therapy for 6 wks

maintenance

pyrimethamine 100mg loading dose,50mg/d

25mg/d

sulfadiazine 4g/d 2g/d

Folinic acid 10mg/d 10mg/d

• In case of sulfa allergy :(sulfadiazine replaced )

-tmp 5mg/kg+smx 25mg/kg od

-clindamycin 600mg tds

-dapsone 100mg od

-atovaquone 750 mg qid

• In case of seizures – carbamazepine and phenytoin

In Pregnancy

Drugs Amniotic fluid antibody + Amniotic fluid antibody -

Spiramycin 1g po tds 1g po tds

Pyrimethamine 50mg/d 25mg/d

sulfadiazine 4g/d 3g/d

Folinic acid 10mg/d 10mg/d

Treatment duration

---- maintenance regimen is continued till patient’s CD4 count is >200 for 6 continuous months , while on ART

Role of steroids

Steriods are indicated if :

- midline shift

-increased ICT

- rapid deterioration within 48 hrs

Primary prophylaxis

In immunocompromised• If CD4 <100• Toxoplasma antibody –negative -----primary prophylaxis for toxoplasmosis

is to be given tmp(10mg/kg/d)+smx(50mg/kg/d) ------can be discontinued if CD> 200 for 3

continuous months ,while on ART

Health advise

• Immuno compromised • sero negative for toxoplasma

- proper cooking of meat -washing vegetables -personal hygiene

Carry home points

• Toxoplasmosis is the most common cause for SOL brain in HIV

• Most common cause for FND in HIV

• All HIV pts should have baseline screening for toxoplasma

• Negative serology--- consider other causes ,though it doesn’t R/O the disease

• IgM antibody not useful in HIV setting • Health advise and primary prophylaxis –prevents the disease.

THANK YOU