CASE REPORT

Spastic Hemiparesis Sinistra and Multiple Cranial Nerve

Palsy with Brain Abscess
SENIOR CLINICAL CLERKSHIP
Period of March 17th April 21st , 2014

By :
Jovita Kosasih

04101401060

Miko Sapta Sera K

04101401117

Advisor

: Dr. H. A. Rachman Toyo, Sp.S(K)

DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
MOHAMMAD HOESIN GENERAL HOSPITAL
PALEMBANG
2014

ENDORSEMENT PAGE
Case Report

Spastic Hemiparesis Sinistra and Multiple Cranial Nerve

Palsy with Brain Abscess
Presented by:
Jovita Kosasih
04101401060

Miko Sapta Sera K

04101401117

Has been accepted as one of requirements in undergoing senior clinical clerkship period of
March 17th April 21st 2014 in Department of Neurology Faculty of Medicine Sriwijaya
University Mohammad Hoesin General Hospital Palembang.

Palembang, 28 March 2014

Advisor

Dr. H. A. Rachman Toyo, Sp.S(K)

NEUROLOGY MEDICAL RECORD

IDENTIFICATION
Name
Age
Sex
Occupation
Admitted

: Ms. NH
: 13 years old
: Female
: Student
: February 18th, 2014 at pm

ANAMNESIS
Patient was admitted into the hospital due to generalized tonic-clonic seizures.
Around two months before admission, patient suffered from weaknesses in her left side
of upper and lower limbs that got worsened in time. She also suffered from intermittent
throbbing headaches and diplopia. The diplopia was aggravated whenever the patient glanced
to the temporal side.
Four days before admission patient had a fever, and two days later she had two
generalized tonic-clonic seizures attacks. The first seizure attack was 10 minutes long, and
the second was 5 minutes long. There were 30 minutes interval between the attacks. Before
the first attack, patient vomited. Patient lost her consciousness after the attacks.
There was no history of dental or otogenic infection, paranasal sinusitis, head trauma or
a neurosurgical procedure.
This is the first time this patient experienced these conditions.
PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Conciousness
Nutrition
Temperature
Pulse
Respiratory rate
Blood pressure

: CM (E4M6V5)
: Normal
: 37.7 oC
: 80 beats/min
: 20 times/min
: 120/80 mmHg

Heart
Lungs
Liver
Spleen
Extremities
Genital

: No abnormality
: No abnormality
: No abnormality
: No abnormality
: No abnormality
: No abnormality

Psychiatric state
Attitude
Attention

: Cooperative
: Normal

Facial Expression
: Natural
Psychological contact : Natural

Neurological state
Head
Shape
Size

: Moon-faced
: Normocephalic

Deformity
Fracture

: No
: No

Symmetric
Hematome
Tumor
Neck
Position
Torticolis
Nape of neck stiffness

: Symmetric
: No
: No

Fracture pain
Vessel
Pulsation

: No
: No widening
: No disorder

: Normality
: No
: No

Deformity
Tumor
Vessels

: No
: No
: No widening

CRANIAL NERVES
N.I: Olfaktorius nerve
Smelling
Anosmia
Hyposmia
Parosmia
N.II: Opticus nerve
Visual acuity
Campus visi

Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding
N.III: Occulomotorius,
N.IV: Trochlearis, and
N.VI: Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis
Light reflex
direct

Right
No disorder
No
No
No

Left
No disorder
No
No
No

Right
6/6
V.O.D

Left
6/6
V.O.S

No
No

No
No

Yes
No
No

Yes
No
No

Right
Yes
Symmetric
No

Left
Yes
Symmetric
No

Convergent
No
No
No
No abnormality

Convergent
No
No
No
No abnormality

Round
3 mm
Isochor
No

Round
3 mm
Isochor
No

Positive, Normal

Positive, Normal

 consensuil
accommodation
Argyl Robertson

N.V: Trigeminus nerve

Motoric
Biting
Trismus
Corneal reflex
Sensory
Forehead
Cheek
Chin
N.VII: Facialis nerve
Motoric
Frowning
Eyes closing
Giggling
Nasolabial fold
Facial shape
rest
Speaking/whistling
Sensory
2/3 anterior tounge
Autonomy
Salivation
Lacrimation
Chvosteks sign
N.VIII: Statoacusticus nerve
Cochlearis nerve
Whispering
Hour ticking
Weber test
Rinne test
Vestibularis nerve
Nystagmus
Vertigo
N.IX: Glossopharingeus, and
N.X: Vagus nerves
Pharyngeal arch
Uvula
Swallowing disorder
Hoarsing/nasalising
Heart beat
Reflex

Positive
Positive
No

Positive
Positive
No

Right
No disorder
No
Yes

Left
No disorder
No
Yes

Normal
Normal
Normal

Normal
Normal
Normal

Right
Normal
Normal
Normal
Normal

Left
Normal
Normal
Normal
Flattening

No disorder
No disorder

No disorder
No disorder

No disorder

No disorder

No disorder
No disorder
No disorder

No disorder
No disorder
No disorder

Right
No disorder
No disorder
Normal
Normal

Left
No disorder
No disorder
Normal
Normal

No
No

No
No

Right
Symmetric
Symmetric
No
No
Normal

Left
Symmetric
Symmetric
No
No
Normal

 Vomiting
Coughing
Occulocardiac
Caroticus sinus
Sensory
1/3 posterior tounge

Yes
Yes
No disorder
No disorder

Yes
Yes
No disorder
No disorder

No disorder

No disorder

N.XI: Accessorius Nerve

Shoulder Raising
Head Twisting

Right
No disorder
No disorder

Left
No disorder
No disorder

N.XII: Hypoglossus Nerve

Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria

Right
No deviation
No
No
No

Left
No deviation
No
No
No

Right
Sufficient
5
Normal

Left
Decreased
4
Increased

Normal
Normal
Normal
Normal

Increased
Increased
Increased
Increased

Negative
Negative
Negative

Negative
Negative
Negative

Right
Sufficient
5
Normal

Left
Decreased
4
Increased

Negative
Negative

Negative
Negative

Normal
Normal

Increased
Increased

Negative
Negative
Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative
Negative
Negative

MOTORIC
Arms
Motion
Strength
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Trommer
Leri
Meyer
LEG
Motion
Power
Tones
Clonus
Thigh
Foot
Physiological reflex
KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo

 Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Lower
Tropik

Negative

Negative

Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative

SENSORY
No Disorders
PICTURE

VERTEBRAL COLUMN
Kyphosis
Lordosis
Gibbus
Deformity

: No
: No
: No
: No

Tumor
Meningocele
Hematome
Tenderness

: No
: No
: No
: No

SYMPTOMS OF MENINGEAL IRRITATION

Right
Nuchal rigidity
No
Kerniq
No
Lasseque
No
Brudzinsky
Neck
No
Cheek
No
Symphisis
No
Leg I
No
Leg II
No
GAIT AND BALANCE
Gait
Ataxia
: No
Hemiplegic
: Yes, left side
Scissor
: No
Propulsion
: No
Histeric
: No
Limping
: No
Steppage
: No
Astasia-Abasia
: No

ABNORMAL MOVEMENTS
Tremor
: No
Chorea
: No
Athetosis
: No
Ballismus
: No
Dystoni
: No
Myoclonus
: No
VEGETATIVE FUNCTION
Micturition
: No abnormality
Defecation
: No abnormality
LIMBIC FUNCTION
Motoric aphasia
: No
Sensoric aphasia
: No
Apraksia
: No
Agraphia
: No
Alexia
: No
Nominal aphasia
: No

Balance and Coordination

Romberg
: No
Dysmetri
: No
finger finger
: No
finger nose
: No
heel - heel
: No
Reboundphenomenon : No
Dysdiadochokinesis : No
Trunk Ataxia
: No
Limb Ataxia
: No

Left
No
No
No
No
No
No
No
No

LABORATORY FINDINGS
BLOOD (21th March 2014, 11.06 WIB)
Hb
Erythrocyte
Hematocrit
Leucocyte
LED
Thrombocyte
Diff Count
Total Protein
Albumin
Globulin
Total cholesterol
HDL
LDL
Triglyceride
Ureum
Uric acid
Creatinin
Natrium
Kalium
Calcium

:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:

9.9 gr/dl
3.64 x 103/mm3
30 vol%
4500/mm3
58 mm/hour
182.000/mm3
0/1/0/56/32/11
6.2 g/dL
3,9 g/dL
2,3 g/dL
183 mg/dl
46 mg/dL
125 mg/dL
110 mg/dL
39 mg/dL
4,40 mg/dL
0.33 mg/dL
143 mmol/L
4.3 mmol/l
9 mg/dl

Immunoserology
HbsAg
Anti HCV

: Not performed
: Not performed

( Non Reaktif < 0.8 )

(Negatif)

Torch
Toxoplasma Ig M

: < 0,201 IU/mL

(0 3 IU/mL)

SPECIFIC EXAMINATION
Cranium X- Ray
Vertebral column X- Ray
Electroencephalography
Electroneuromyography
Electrocardiography
Arteriography
Pneumography
Head CT-Scan
Head MRI
Lumbal Puncture

(11,7-15,5 gr/dl)
(4.20-4.87 x 103/mm3)
(37-43 vol%)
(4500-11000/mm3)
(<20 mm/hour)
(150.000-450.000)
(0-1/1-6/2-6/50-70/25-40/2-6)
(6,4 8,3 g/dL)
( 3,5 5,0 g/dL)
( 2,6 3,6 g/dL)
(<200 mg/dl)
( >65 mg/dL)
( <100 mg/dL)
(<150 mg/dL)
(16,6-48,5 mg/dL)
(5,7-14)
(0,5-0,9)
(135-155 mmol/L)
(3,6-5,5 mmol/L)
(8,8 10,2 mg/dL)

: Not performed
: Not Performed
: Not performed
: Not performed
: Not performed
: Not performed
: Not performed
: Not performed
: Performed
: Not performed

RESUME
IDENTIFICATION
Name
Age
Sex
Occupation
Admitted

: Ms. NH
: 13 years old
: Female
: Student
: February 18th, 2014 at pm

Ms. NH, female, 13 years, admission date 18th of February 2014

ANAMNESIS
Patient was admitted into the hospital due to generalized tonic-clonic seizures.
Around two months before admission, patient suffered from weaknesses in her left side
of upper and lower limbs that got worsened in time. She also suffered from intermittent
throbbing headaches and diplopia. The diplopia was aggravated whenever the patient glanced
to the temporal side.
Four days before admission patient had a fever, and two days later she had two
generalized tonic-clonic seizures attacks. The first seizure attack was 10 minutes long, and
the second was 5 minutes long. There were 30 minutes interval between the attacks. Before
the first attack, patient vomited. Patient lost her consciousness after the attacks.
There was no history of dental or otogenic infection, paranasal sinusitis, head trauma or a
neurosurgical procedure.
This is the first time this patient experienced these conditions.
PHYSICAL EXAMINATION
Conciousness (GCS score) : GCS 15 (E4 M6 V5)
Blood pressure

: 120/80 mmHg

Pulse rate

: 80 x/m

Respiration rate

: 20 x/m

Temparature

: 37.7 C

Neurological examination:
N II

: papilledema

N III

: round pupil, isocoria, Light reflex +/+, diameter 3 mm

N VI : bilateral paresis
N VII : flattening of left plica nasolabialis
N XII : no tongue deviation

Motoric function

Right trunk

Left trunk

Right arm

Left arm

Movement

Sufficient

Reduced

Sufficient

Reduced

Strength

Tonus

increased

increased

Clonus
Physiological ref.

increased

increased

Pathological ref.

Sensory function

: normal

Limbic function

: normal

Vegetative function

: normal

Meningeal signs

:-

Abnormal movements : Gait dan balance

: Hemiplegic gait (+)

SPECIFIC EXAMINATION
MRI
: Lesi bentuk oval, batas tegas, tepi ireguler, terukur sekitar AP 3.1 x
LL 2,5 x CC ,64 cm dengan gambaran double rim sign dan ring
enhancement pada ganglia basalis kanan yang mendesak ventrikel
lateral kornu anterior kanan, menyebabkan midline shifting minimal ke
kiri disertai edema cerebri luas pada sekitarnya cenderung gambaran
abses serebri. Terdapat tanda peningkatan TIK saat ini.
DIAGNOSIS
Clinical diagnosis

: Spastic Hemiparesis Sinistra and Multiple Cranial Nerves Palsies

Topical diagnosis

: Ganglia Basalis

Etiology diagnosis

: Brain abscess

MANAGEMENT
Non-pharmacology

: Diet tinggi kalori tinggi protein

Pharmacology

: - Metronidazol 30mg/kgBB/hr
- Ceftriaxone 2 x 100mg/kgBB/hr
- Vancomisin 4 x 60 mg/kgBB/hr
- Fenitoin 2 x 100mg
- Deksametason 4 x 5mg iv

Planning

: MRI ulang setelah 2 minggu terapi

PROGNOSIS
Quo ad vitam
Quo ad functionam

: Dubia ad bonam
: Dubia ad bonam