MANILA DOCTORS HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

667 United Nations Avenue
1000 Manila, Philippines

Case Protocol

The Seafarers Wife

Moderator:

Reactors:
Dr. Astejada
Dr Dioquino
Dr Roman
Dr Salvana

Presentor:
Olivia Faye J. Listanco, M.D.
Medical Resident, Yr Level I

CASE PROTOCOL

Objectives:
1) To present a case of a patient with HIV presenting with neurologic deficit
2) To discuss the diagnosis and management of intracranial mass in an HIV patient

This is a case of COV, 46, Female, from Tagytay City, Cavite, Married, Roman Catholic, and works as a
fitness instructor. She was admitted at Manila Doctors Hospital last April 4, 2015.
Chief Complaint: Unsteady gait
History of Present Illness
Three months PTA, patient was noted to have weakness of her right arm described as inability to carry her
child. She denied any history of trauma. Patient then sought consult at a local hospital where patient was advised to
undergo a cervical CT scan. Patient claimed she was then diagnosed to have brachial plexus palsy. She was
advised to undergo rehabilitation therapy which she underwent for 3 sessions with noted improvement of her grip
strength.
One week PTA, patient then experienced light headedness associated with unsteadiness of gait and
tendency to fall. She denied any weakness, slurring of speech or headache at that time.
Symptoms persisted until three days PTA, patient decided to seek consult at Tagaytay Hospital where
patient was subsequently admitted for work up. Patient claimed that laboratory tests done yielded normal results. She
was then advised to have cranial CT scan done hence decided to 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 drinker; no known illicit drug use
Claimed 2 sexual partners (first husband (deceased) and current husband)
Used to work in Africa for 10 years

Frequently travels to Mexico

Family History:
(+) T2DM - mother
(-) hypertension, (-) cerebrovascular accidents, (-) cardiac disease
ROS:
(-) fever
(-) behavioural changes
(-) anorexia
(-) chest pain
(+) Anorexia since last January with unqualified weight loss
Physical Exam at the ER:
BP: 120/70
HR: 80
RR: 20
Temp: 36.5
GCS15
Non labored breathing
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

Laboratory tests done included CBC, BUN, creatinine, lipid profile, FBS, and SGPT. Other electrolytes were not done
since were already done from previous hospital. Cranial MRI with contrast and 12 lead ECG were also requested.
Admitting Impression: D7 Cerebellar infarct, R/O Cerebellar mass; Brachial nerve palsy
Course in Wards:
1st Hospital Day:
Patient admitted at the floors and managed as a case of cerebellar infarct. No reports of headache or
slurring of speech noted. Patient remained with stable vital signs.
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, 2-3/5 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
Neck supple
(-) Babinski (-) Clonus
Patient was put initially on complete bed rest without bathroom privileges and started on 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 service and cranial MRI was requested 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.
2nd HD:
Patient was noted to have one episode of twitching of her right upper extremity lasting for less than 3
minutes. No associated loss of consciousness. Vital signs remained stable and patient was seen after the seizure to
be awake, and oriented. Patient was also noted to have a shallow left nasolabial fold and tongue deviation to the left.
Patient was put on seizure precaution. Started on Leviteracetam 500mg/tab BID and diazepam 5mg/IV PRN
for frank seizure. EEG was also requested. Impression at that time was 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 service the started the patient on Dexamethasone 5mg IV Q8 and Leviteracetam was
continued. Patient was then referred to IDS service for co-management with the impression of Intracranial Mass
Probably sec to Opportunistic infection, R/O Herniation syndrome R/O HIV infection
4-5th HD
Vital signs remained stable and without noted progression/ new onset deficits. IDS service requested for HIV
screening (code 173) as well as other work up which included Chest x-ray, TPHA (quantitative), Toxoplasma IgG and
IgM and PPD test. Patient was also started on Ceftriaxone 2gm IV Q12 and Metronidazole 500mg IV Q6. Revised
impression was Intracranial mass probably secondary to infection Prob 1. Abscess, 2. Toxoplasma, 3. Syphilis, 4.
Tuberculoma; R/O Herniation syndrome
6th HD:
Patients neuro status and vital sign remained stable. EEG results showed intermittent slowing of
background activity over frontal region suggestive of focal pathology over the said region. Leviteracetam was
continued. Chest xray done also revealed no active infiltrates or lesion, hence AFB smear was deferred.

7-9th HD:
Patient tested for Toxoplasma and was noted to be IgM negative and IgG positive. TPH was noted to be
positive up to 1:1280 dilutions. Patient was the treated for Toxoplasma and syphilis infection. CD4 and CD8 counts
were requested. Dexamathasone was reduced to 5mg IV Q12. Antibiotics started were Ceftriaxone 2gm IV Q12,
Metronidazole 500mg IV Q6, and SMX TMP 800/60 BID to be completed for 4 weeks. 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.
Rehabilitation therapy was also started. Patient was also referred to CNMS for nutritional build-up of the
patient.
10th HD:
Patient was noted with whitish plaques on the oral mucosa and was started on Fluconazole 150mg TID.
Repeat CT scan with contrast was also requested. Dexamethasone was also shifted to Dexamethasone 4mg/tab
BID. Patient was cleared for possible discharge.
12th HD:
CD4 count revealed a value of only 49 and CD8 count at 422. Patients partner was also advised HIV
screening as well. During patients course of admission, 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 stable and improved.

Laboratory Results
4/3/5
(done
outside)
105
21
4.7
70
13
198
Normocytic
hypochromic

4/4/15

Creatinine
BUN
ASL

60
3.9

53

Na
K

133
4

Hgb
Hct
WBC
Neutrophil
Lymphocyte
Platelet
PBS

FBS
Cholesterol
/Triglyceride/
HDL/LDL
TSH
FT3
FT4
ANA
ESR

4/5/15

4/6/15

4/7/15

4/8/15

107
30
5.29
62
16
197

25

75.6
102.6/140.8/
26.6/57
2.51
4.81
12.9
0.953
66.0

RPR with titer

Cryptococcal
Antigen Latex
Agglutination
T. pallidum Heme
agglutination

Toxoplasma IgM

Toxoplasma IgM

4/11/15

Reactive
1:1 dilution
Negative

Positive
up to
1:128
dilution
0.735
Negativ
e
1.819
Positive

PPD

Negativ
e

CD4 (%)
CD4/ mm3
CD8 (%)
CD8/ mm3
CD4/ CD8

7.79
49
67.01
422
0.1

Urinalysis (4/3/15)
pH 6.0 Specific gravity 1.005 Protein Negative Glucose Negative WBC 3-6 RBC 0-2 Bacteria +3 Epithelial cells Few
Fecalysis (4/3/15)
+ bacteria, No parasite seen, Negative occult blood
Imaging
Cervical MRI (4/1/15)
Mild cervical canal stenosis with mild cord compression at levels C4-C5. Mild broad based disc bulge C6-7.
CXR (4/7/15)
Lungs are clear. Normal heart, diaphragm, sulci, and bony thorax.
EEG (4/6/15)
Abnormal EEG due to intermittent slowing of background activity ober both frontal region suggestive of focal pathology.
Cranial MRI (4/6/15)
No evidence of acute infarct. Multiple signals scattered in the cortical regions, some larger lesions with corresponding rimenhancement. The largest lesion in the right parietal lobe is associated with moderate to severe vasogenic edema with resultant
mild compression of the right lateral ventricle and 3mm, right to left subfalcine herniation. Considerations include infectious
process and metastasis.