Klinik Kesehatan dr.Bobby M: Kasus II

A 60-Year-Old Woman With Sudden-Onset Left-Sided Weakness

Background

Figure. A CT scan of the brain showing infarction of the right middle cerebral artery

A 60-year-old, right-handed woman is brought to the emergency department (ED) for left-sided weakness following an unwitnessed fall. She fell to the floor on her left side while attempting to get out of bed. She realized that her entire left side was weak, and she did not have the strength to stand up on her own. Her family states that she has been sleeping much more than normal and had complained of a severe occipital headache for the last 3 days accompanied by 6-7 episodes of vomiting per day. The vomiting is not relieved by antacids and proton-pump inhibitors, and it is not associated with nausea. She also complained to her family of feeling feverish for the past few days and had appeared intermittently agitated. She denies any history of head trauma, photophobia, diplopia, convulsions, dizziness, difficulty speaking, or difficulty swallowing.
Her past medical history is significant for a hysterectomy 15 years ago and an appendectomy at age 13. There is no prior history of stroke, transient ischemic attacks, hypertension, coronary artery disease, rheumatic heart disease, or atrial fibrillation. She reports no allergies. On review of her family history, she reports that her husband was diagnosed with pulmonary tuberculosis 10 months ago. She states that he was treated with antituberculosis medications for a period of 6 months but admits that he had not been compliant with the entire course of treatment.
She does not smoke tobacco, drink alcohol, or use illicit drugs. She has never used oral contraceptive agents. She lives in Mumbai, India, and has never travelled abroad.
On physical examination, her oral temperature is 99.6°F (37.6°C). Her pulse is regular, with a rate of 60 beats/min. Her blood pressure is 130/80 mm Hg, and her respiratory rate is 10 breaths/min. Auscultation of the heart reveals a normal S1 and S2, with no murmurs or rub. Palpation of the abdomen reveals no tenderness, masses, or enlargement of the liver or spleen. The lungs are clear in all fields except for slight coarse sounds heard over the right lung field. The patient appears to be drowsy and disoriented. She follows commands poorly, withdraws from painful stimulus, and her total Glasgow Coma Scale score is 10. She is breathing spontaneously and appears to be controlling her secretions. There is no evidence of trauma on head-to-toe examination. Cervical lymph nodes are palpable and are measured at 2-3 cm in diameter. Both pupils are 3 mm in size and are reactive to light. She is unable to flex her neck (meningismus) and, on forceful flexion, there is partial flexion of both right and left thighs (positive Brudzinski's sign). Muscle strength in the left upper and lower limbs is decreased at grade 2/5, or full range of motion without gravity, while reflexes in the same extremities are brisk and excessive. Both the strength and the deep tendon reflexes on the right side are normal. The plantar reflex is positive for Babinski's sign bilaterally. There is also left hemianesthesia and left homonymous hemianopsia. The rest of the cranial nerve examination was normal.
The laboratory analysis includes a complete blood count that reveals an elevated total leukocyte count of 13.5 x 10³/μL (normal range = 4.0-10.0 x 10³/μL) with 56% lymphocytes (normal range = 20%-45%) and an elevated erythrocyte sedimentation rate of 80 mm/hour (normal range = 0-20 mm/hour in females). Other biochemical investigations reveal hyponatremia, with sodium levels at 120 mEq/L (normal range = 135-145 mEq/L), while potassium and chloride levels are normal. Serum glucose is 78 mg/dL. Tests for HIV I and II are nonreactive, and liver function tests are normal. A lumbar puncture is performed that reveals hazy cerebrospinal fluid (CSF), with an elevated protein count at 156 mg/dL (normal range, 10-60 mg/dL) and a decreased glucose level of 35 mg/dL (normal range = 40-80 mg/dL). On microscopic examination, the CSF has an elevated total cell count of 40 cells/mm³ (normal range, 0-5 cells/mm³), with 90% of cells being lymphocytes.
A CT scan shows a hypodense area in the distribution of the right middle cerebral artery that is consistent with a cerebral infarction.