Grand case report

Secondary Headache
By:
Mutia Dewi Assifa

Supervisor:
dr. Riki Sukiandra, Sp.S

CLINICAL CLERKSHIP DEPARTMENT OF NEUROLOGY

RSUD ARIFIN ACHMAD
FACULTY OF MEDICINE UNIVERSITY OF RIAU
PEKANBARU
2020
PATIENT’S IDENTITY
Name Mrs. U
Age 47 years old
Gender Female
Address Siak

Religion Islam
Marital status Married
Occupation Housewife
Date of hospital admission December, 30th 2019
Medical record 0132xxx
Chief complaint

Headache since two weeks before

admitted to the hospital
Present illness history
2 weeks before admission
Headache, comes in sudden
and felt more worsening, give
any impact on her daily
activity. Patient didn’t
consume any drugs for her
complain. It following by
fever, nausea, and vomit. She
vomitting 4 times a day but
did not spurting out. She also
experienced numbness on her
lower extremity.
2 days before admission
Patient was seizure, happen 3
times a day in whole body.
When the seizure was
happened, the patient was
stiffen, in this phase she was
lost her conciusness. Then
following by jerk and twitch
ritmically and regaining
conciousness slowly. Once it
happened in 3-5 minutes.
According to the report of
emergency room. The patient
was in apatis condition.
Past illness history

HIV-seropositive since April 2019.

Initiated ART since April 2019 ago but dropped out in the last 4
months because she has consuming Anti-Tuberkulosis
treatment.

TB infection since Agustus 2019 and has iniated by

antituberculosis treatment
Socioeconomic history
• The patient is currently a housewife, but 5 years ago worked as
a household assistant.

Family disease history

Second husband : HIV-seropositive and had passed

away in 2011 due to opportunistic infections.

Children : not infected.

RESUME
• Mrs. U, 47 years old was admitted to the hospital with
headache since 2 weeks before. The complain was
following by a high fever, seizure, nausea, vomit, and
also numbness on her right lower extremity and
difficulties when walking. She didn’t consume any drugs
for her complaint. The patient has been diagnosed with
HIV infection in April 2019 and has initiated ART but
dropped out in August 2019. Her second husband also
infected by HIV.
Generalized condition
BP 104/60 mmHg
Pulse 60 bpm, regular
RR 20 tps, thoracoabdominal
T 37,00C
Weight/Height/BMI 55 kg/155 cm/22,9 kg/m2 (normoweight)
Eyes Pale conjunctiva (-/-), mid-position fixed pupil
Cardiovascular HR 140 bpm, regular, murmur (-), gallop (-)
Respiratory Vesicular (+/+), rhonchi (+/+), wheezing (-/-)
Abdomen Normal skin turgor, bowel sounds 8 tps
Lymph nodes Swollen lymph nodes (-)
Neurological status

Composmentis Cooperative
Consciousness
(E4V5M6)
Cognitive
Normal
function
Nuchal rigidity Negative
Cranial nerves - Olfactory
  Right Left Interpretation

Sense of smell Normal Normal Normal

Cranial nerves - Optic

  Right Left Interpretation
Visual acuity
Visual fields Normal Normal Normal
Colour recognition
Cranial nerves - Occulomotor
Right Left Result
Ptosis (-) (-)
Pupil    
Shape Round Round
Size 3 mm 3 mm

Pupillary reflex     Normal

Direct (-) (-)
Indirect (-) (-)
Cranial nerves - Trochlear
  Right Left Interpretation

Extraocular
Movement (+) (+) Normal

Cranial nerves - Trigeminal

  Right Left Interpretation

Motoric
Sensory Normal Normal Normal
Corneal reflex
Cranial nerves - Abducens

  Right Left Interpretation

Eyes movement Normal Normal

Normal
Strabismus (-) (-)
Corneal Refleks (-) (-)
Cranial nerves - Facial

Interpretatio
Right Left
n
- Tic motor (-) (-)
- Frowning Normal Normal
- Raised eye brow Normal Normal
- Close eyes Normal Normal 
Normal  
- Corners of the Normal
mouth   Normal
- Nasolabial fold Normal Normal  
- Sense of taste Normal Normal
- Chovstek Sign (-) (-)
Cranial nerves - Vestibulocochlear
  Right Left Interpretation
Normal Normal Normal
Hearing sense

Cranial nerves - Glossopharyngeal

  Right Left Interpretation

Arcus faring Normal Normal

Normal
Flavor sense Normal Normal
Gag reflex (+) (+)
Cranial nerves - Vagus
  Right Left Interpretation

Arcus pharyng Normal Normal Normal

Dysphonia (-) (-)

Cranial nerves - Accessory

  Right Left Interpretation

Motoric Normal
Trophy Normal Eutroph Normal
Eutrophy
y
Cranial nerves - Hypoglossal
  Right Left Interpretatio
n
Motoric Normal Normal
Trophy Eutrophy Eutrophy
Tremor (-) (-)
Dysarthria (-) (-) Normal
Sensory
Interpretatio
  Right Left
n
Touch
Pain Difficult to Difficult to
Temperature assess assess

Proprioceptive
 Position Not testable   
 Two point
Difficult to Difficult to
discrimination
 Stereognosis assess assess
 Graphestesia
 Vibration
Motoric
  Right Left Interpretation
Upper Extremity    
Strength Difficult to assess Difficult to assess
  Normal Normal
Tone Eutrophy Eutrophy
Trophy (-) (-)
Involuntary movements (-) (-)
Muscle strength not
Clonus
testable, tone and trophy
Lower Extremity     are normal
Strength Difficult to assess Difficult to assess
  Normal Normal
Tone Eutrophy Eutrophy
Trophy (-) (-)
Involuntary movements (-) (-)
Clonus
Body    
Trophy Eutrophy Eutrophy  
Involuntary movements (-) (-) Normal
Abdominal Reflex (-) (-)
Lateralization
Normal Fall faster Lateralization (+)
(passive)

Abnormal
extension Decreased response to pain
Response to pain stimulus Abnormal extension
(decreased on the left side of the body
response)
Reflexes
  Right Left Interpretation
Physiologic    
Biseps (+) (+) Physiologic
Triseps (+) (+) reflex (+)
Patella (+) (+)  
Achilles (+) (+)

     
Pathologic
(-) (-)  
Babinsky
(-) (-)  
Chaddock
(-) (-) Pathologic reflex
Hoffman-Tromer
(-) (-) (-)
Oppenheim
(-) (-)  
Schaefer
     
Coordination
  Right Left Interpretation
Point to point movement
 
Walk heel to toe
Difficult Difficult Not testable
Gait
to assess to assess  
Tandem
 
Romberg

Autonom
• Urination : Urine catheterization is installed
• Defecation : Not testable
Other examination
Laseque NT
Kernig’s NT
Patrick NT
Contrapatrick NT

Valsava test NT
Naffziger NT
Brudzinski Negative
RESUME
• Semi coma (E1V1M2)
• Tachycardia, tachypnea, hyperpireksia
• Meningeal signs negative
• Midposition fixed pupil, doll’s eyes movement (-), cornea
reflex (-)
• Muscle strength not testable, tone and trophy are normal,
lateralization (+), decreased response to pain on the left side of
the body
• NGT : dark gastric residue
WORKING DIAGNOSIS

Clinical : Increased intracranial pressure syndrome, brain herniation syndrome

Topical : Right cerebral hemisphere

Etiological : Cerebral abscess ec. Susp. toxoplasmosis

DD : Cerebral abcess ec. Cerebral tuberculoma

Secondary : HIV-seropositive, sepsis

Suggestive examinations
• Blood routine test
• Blood chemistry test
• Electrolyte
• Serum IgG anti-toxoplasma and IgG avidity
• Serum CD4 level
• Head CT-Scan with contrast
• Thoracic X-Ray
MANAGEMENT
• O2 2-3 lpm
• IVFD RL 20 dpm
• Dexamethasone 4 x 5 mg IV
• Sulfadiazine 4 x 1000 mg via NGT
• Pyrimethamine 4 x 50 mg (loading dose) via NGT
• Ceftriaxone 2 x 1 gr IV
• Paracetamol 3 x 1 gr IV
• Consult to internist and VCT
• Indicated to be hospitalized in high care unit (HCU)
LAB FINDINGS

Blood routine:
Blood chemistry:
• Hb : 13,3 g/dl
• Glu : 212 mg/dl
• Leu : 22.350/mm3
• Ur/Cr : 28/0,72 mg/dl
• Thromb :
• AST/ALT : 44/85 U/L
350.000/mm3
• Ht : 39,9%
Electrolyte:
• Neut : 85,9%
• Na+ : 131 mmol/L
• Lymph : 8,1%
• K+ : 3,0 mmol/L
• Mono : 6%
• Cl- : 100 mmol/L
• Eosin : 0
Head CT Scan (no contrast)
Interpretation :
• Circular isodense lesion at right basal
ganglia with perifocal oedema at
bilateral paraventricular area
• Shallow sulci, flat gyrus and sylvian
fissure disappeared relatively
• Diffuse white and grey matter junction
• Ventricular system minimally narrowed
• Midline shift (-)

Conclusion :
Susp. multiple bilateral paraventricular
SOL with perifocal oedema + cerebral
oedema

Suggestion : head CT-scan with

contrast.
FINAL DIAGNOSIS

Cerebral abscess + HIV-seropositive

+ sepsis.
Follow up
July 23, 2019

Assessment
• No improvement of • Dexamethasone was
consciousness added to the therapy
• No response to • Cerebral abscess + list
antipyretic therapy, sepsis + HIV • Consulted to internist
the body temperature infection and VCT
remains high
Subjective &
Plan
Objective
Follow up
July 24, 2019

Assessment
• No improvement of • No additional therapy
consciousness • No therapy from the
• Body temperature • Cerebral abscess + internist
decreased (380C) sepsis + HIV infection • VCT consultation 
ART initiated when
general condition
improved
Subjective &
Plan
Objective
Follow up
July 25, 2019

Assessment
• No improvement of • No additional therapy
consciousness • Consulted to
• Body temperature • Cerebral abscess + respirology and
increased (390C) sepsis + HIV infection pulmonology
• Lungs ausc. : rhonchi specialist
(+/+)
Subjective &
Plan
Objective
Follow up
July 26, 2019

Assessment
• No improvement of • IVFD RL : Aminofluid =
consciousness 1:1 20 dpm
• No response to antipyretic • Cerebral abscess + sepsis • Sputum test (GenExpert)
therapy, the body + HIV infection • Serum CD4 level
temperature remains high
• Lungs ausc. : rhonchi
(+/+)
Subjective &
Plan
Objective
Follow up
July 27, 2019

Assessment
• GCS : E1V2M2 • No additional
• Body temperature • Cerebral abscess + therapy
increased (39,70C) sepsis + HIV
• Waiting for
• Lungs ausc. : infection sputum test and
rhonchi (+/+) serum CD4 level
results
Subjective &
Plan
Objective
Follow up
July 28, 2019

General condition worsen, the patient was apnea and passed away at 2 a.m.
DISCUSSION
Basic clinical diagnosis

Increased intracranial pressure

syndrome

Altered level of consciousness and headache are two

of three clinical manifestations of increased
intracranial pressure syndrome, projectile vomiting
is absent in this patient.
Basic clinical diagnosis

Brain herniation syndrome

Mid-position fixed pupil, absence

of brainstem reflexes
Basic clinical diagnosis

Sepsis

Sepsis results when an infectious insult triggers a localized

inflammatory reaction that then spills over to cause
systemic symptoms of fever or hypothermia, tachycardia,
tachypnea and either leukocytosis or leukopenia.
Basic topical diagnosis

Right cerebral
hemisphere
Focal neurological deficits indicate the cause
of intracranial process. Lateralization and
decreased response to pain on the left side of
the body indicates lesion on the right side of
the hemisphere. From the present illness
history, the patient also complained
numbness and difficulties when walking on
the left side of the body.
Basic etiological diagnosis

Fever is the most frequent clinical manifestations

which indicates infection due to immune
response. In HIV/AIDS patients, the low level of
CD4 cell count, the failure of IL-12 and IFN-ɤ
production makes them more vulnerable to have
opportunistic infections.
Basic work up
Blood routine test  to find any change that show infection

Blood chemistry test and electrolyte  to find whether there is any

extracranial process involved

Serum IgG anti-toxoplasma  to detect anti toxoplasma antibody

Serum CD4 level  assessing patient’s immune status and associated to

the initiation of primary prophylaxis

Head CT Scan  to find intracranial cause of the altered level of

consciousness

Thoracic X-Ray  to find any other possible etiology

Basic treatment
Sulfadiazine & pyrimethamine  presumptive therapy

Dexamethasone  to reduce cerebral oedema and so an altered level of

consciousness

Omeprazole and ranitidine  to treat the stress ulcer

Paracetamol  antipyretic, symptomatic therapy

Ceftriaxone  broad spectrum antibiotics to treat sepsis

THANK YOU