Clinical Pathological Case Competition Jennifer Khawand DO , PGY-4

1. Clinical Pathological Case Competition Jennifer Khawand DO, PGY-4 St. Mary Mercy Hospital EM Residency

2. HPI 50 year old male with history of diabetes presents to the emergency room with complaints of confusion. Tonight the patient was in his bed and his partner states that he was not acting like himself and complaining that he felt fatigued. He was confused and not making sense when speaking and there was concern for the patient having slurred speech and facial droop. On arrival to the ER the patient is complaining of a headache in the occipital region of his head and some blurriness in his vision that started over the past 2 hours. It is noted that he now has clear speech and no signs of facial droop. For the past 3 days patient has had a decreased appetite and has been refusing fluids. He was diagnosed with bronchitis approximately 5 days ago in a different ER when he had complaints of a cough and temperature of 101. He was given an albuterol inhaler for a diagnosis of bronchitis and had been using them as needed.

3. Past Medical History Past Medical History: Diabetes mellitus type II Past Surgical History: Appendectomy Family History: Brain aneurysm in mother Social History: Patient drinks alcohol regularly on weekends, Denies Tobacco use, Denies Drug use. He has been in a long term relationship with his male partner for the past 20 years. Allergies: No known drug allergies Medications: Metformin 500 mg BID

4. Review of Systems Constitutional symptoms: No current fever or chills Skin Symptoms: No rash Eye Symptoms: + Blurred vision ENMT symptoms: No sore throat; no nasal congestion Respiratory Symptoms: + Cough, no shortness of breath Cardiovascular Symptoms: No chest pain, no palpitations, no syncope Gastrointestinal symptoms: +Nausea, No abdominal pain, no vomiting, no diarrhea. Genitourinary symptoms: No dysuria, no hematuria Musculoskeletal symptoms: No back pain, no muscle pain Neurologic symptoms: +Headache, +altered level of consciousness, no dizziness, no numbness , no tingling

5. Physical Exam Heart rate: 48; Respiratory Rate: 16; Blood Pressure 151/90; Pulse oximetry: 93% on room air General: Alert, No acute distress Skin: Warm, dry, no pallor Head: Normocephalic, atraumatic Neck: Supple, No stiffness Eyes: PERRL, extraocular muscles intact, normal conjuctiva Cardiovascular: Regular rhythm, Bradycardia, no mumur, no edema Gastrointestinal: Soft, nontender, nondistended Neurological: No focal neurologic deficits, CN II-XII intact, normal motor strength in the major muscle groups, sensory intact to light touch in the facial regions and all 4 extremities, Patient alert and oriented to person only. Abnormal finger to nose of right hand; Speech normal

6. Initial Tests Ordered • CBC, BMP, Lactic Acid, Troponin, Acetone, PTT, PT, INR, fingerstick glucose, Blood cultures • EKG, Xray Chest, CT head without contrast

7. EKG • Sinus Bradycardia , HR 52, Normal PR and QRS intervals, T wave inversions in the inferolateral leads, No ST elevation

8. Labs Acetone (ketones) Qualitative Negative Fingerstick Glucose 140 Cardiac Enzymes Troponin I 0.08 ng/ml Myoglobin 74 ng/mL Coags PT 12.2 sec PTT 25.6 sec INR 1.1 CBC WBC Count 6.6 thou/mcL Hemoglobin 13.2 gm/ dL Hematocrit 37.8 % Platelet count 250 thou/mcl Neutrophil Absolute 4.7 thou/mcL Lymphocyte Absolute 1.5 thou.mcL BMP Sodium 140 Potassium 3.8 Chloride 105 Anion Gap 14 Glucose 158 BUN 12.2 Creatinine 0.70 GFR 119 Calcium Total 8.6

9. Chest Xray

10. Chest Xray • Slightly Low lung volumes. No consolidation, pleural effusion, pneumothorax or congestion. No mass lesion • Cardiomediastinal silhouette and pulmonary vasculature within normal limits for technique • Visualized osseous structures are unremarkable

11. CT Head without Contrast

12. CT Head without Contrast

13. CT Head without Contrast • Multiple Foci of abnormal low attenuation within the bilateral cerebral and cerebellar hemispheres with apparent sparing of the gray matter suggestive of vasogenic pattern of edema. • Expansion and hyperdensity of the right cerebellar hemisphere suggestive of mass lesion as detailed above. • There is effacement of the prepontine cistern and crowding of the foramen magnum

14. CT Head with Contrast

15. CT Head with Contrast

16. CT Head with Contrast • Redemonstration of posterior fossa mass lesion centered in the region of the right cerebellar hemisphere with a portion extending into the 4th ventricle which demonstrates vague enhancement. • Redemonstration of focal patchy areas of low attenuation with the bilateral cerebral hemispheres. • No supratentorial enhancing lesions are identified. The ventricles are somewhat prominent and the findings may be related to transependymal flow secondary to acute/subacute hydrocephalus. However the patchy appearance would be atypical and differential considerations include infectious, demyelinating and neoplastic processes.

17. ED course • Patient was started on broad spectrum antibiotics due to wide differential diagnoses from CT scan and was also given a dose of decadron due to the vasogenic edema. • He became increasingly more confused and agitated throughout his ED course with evidence of hallucinations, disorientation and restlessness. • The intensivist, infectious disease, neurologists, neurosurgeon were consulted. Due to the patient’s history the intensivist recommended obtaining screening tests for HIV as patient’s partner stated that he had never been tested. • Radiologist recommended obtaining an MRI. He was intubated and sedated with a propofol drip in order to undergo an MRI. • Following MRI patient was transferred to the ICU.

18. MRI Brain with contrast

19. MRI Brain with contrast • Multifocal signal lesions in both cerebrum and cerebellum with surrounding vasogenic edema. • Ring enhancing lesions in the left frontal lobe, approximately 1 cm, left parietal lobe 1 cm and the left cerebellar hemisphere and also in the right lentiformnuclei