neurology
consulted for limb weakness
allergic to ciprofloxacin
chronic smoker for 50 years, non-drinker
PMH: LUTS, right renal stone with OT
case of cystitis / prostate abscess complicated with septic shock, AKI, ARDS, Waterhouse-Friderichsen syndrome
history clarified with patient and wife:
acute onset left hand numbness (radial 4 fingers + palm) 23/9 pm, did not notice left hand weakness, still able to complete his work as a driver that day
attended AED 24/9 for the left hand symptoms (AED notes documented the attendence was for upper back pain), WCC 16 neutrophilia, dispensed tramadol / maxolon
developed generalized malaise after taking meds from AED, sleeping throughout most of the day 25-27/9
accompanied wife to china for dental checkup 28/9 am, acute worsening of patient’s consciousness at 2pm that day, noted to be poorly responsive with generalized weakness at SZB while returning to HK, attended by staff and found to be febrile, sent to AED
no unilateral weakness / facial asymmetry / diplopia / dysphagia / sphincter disturbances / prior cognitive impairment
no headache / neck pain / seizure / OTC meds / herbs
on admission SBP 130, HR 110, 38C, RA, hstix 6.6, GCS and limbs power full
WCC 15 eosinophilia, LRFT INR N, CRP 200, blood urine c/st -ve
29/8: seen by neurology for left IF flexor weakness, no other focal weakness, imp: suspected left AIN palsy
31/8: wife noted patient to have decreased verbal response, slurred speech, poor oral intake, and decreased right side limb movement since 30/8 during visiting hours
PE: GCS full, right > left 4 limb weakness (R 4/3; L 5/4) with right facial weakness and slurred speech; SBP 120, fever 38C
CTB: right posterior watershed patchy hypodensities
right hemiplegia trough at 0/5
1/9: complicated with septic shock required ICU support and high dose inotropes; CT A+P: prostate abscess / cystitis; AKI, ARDS; stabilized and discharged to general ward 10/9
17/9: ORT: left proximal median nerve palsy
23/9: acute onset left lower limb weakness (R 4/3; L 4/4-), PR tone grip sensation normal, serial CTB: interval established right posterior watershed and left pontine infarct, ventricular size static
CXR: no cardiomegaly
ECG: SR, no LVH
A1c 6.3, LDL 0.9
echo: unremarkable
holter: no AF
ESR / CRP normalized
TP EIA HIV -ve
lactate N
GCS full
no ptosis, PEARL, EOM / saccades normal, right UMN facial weakness
4+/5-
proximal 3, distal 4+ / proximal 4+, distal 5
bilateral pyramidal weakness R>L
right pronator drift, right UL overshoot
tone normal
generalized hyporeflexia, no ankle clonus, flexor plantar responses
no sensory level
no dysmetria / disdiadochokinesia
gait: narrow based, failed tandem walking, romberg -ve
left hand
impaired thumb / index finger flexion on making a fist
unable to perform the ok sign or thumb / LF opposition
finger long flexor weakness across the ulnar 4 fingers
finger abduction weakness, froment +ve
finger extension weakness, wrist extension power full
imp:
acute onset left IF weakness; acute onset right hemiplegia with right facial weakness; acute onset left LL weakness; symptoms were worst at onset with interval recovery
in the clinical context of prostate abscess with severe septic shock
CTB showed interval development of right posterior watershed and left pontine wedge shaped hypodensities with grey white involvement
the clinical presentation was likely compatible with recurrent acute ischemic stroke involving different vascular territories
the likely stroke etiology may be a perfusion infarct in the setting of severe systemic hypotension on top of possible large vessel disease; ddx embolic
RF: chronic smoker, no other known vascular risk factors
left hand examination demonstrated deficits beyond in the left median nerve to involve the left ulnar and radial nerve innervated muscles; taking note that findings at this juncture can be overshadowed by the left sided ischemic stroke
suggest
– await contrast MRI brain / MRA head and neck to clarify the diagnosis and exclude alternative infective / inflammatory pathology given the atypical presentation, red flag (concurrent severe systemic sepsis), and recurrent neurological symptoms
– review the need for further embolic stroke workup after large vessel disease excluded
– await NCT / USG left forearm to clarify the presence of a concomittant peripheral neuropathy