GRAND ROUNDS CASE PROTOCOL

“My Young Fair Lady”

JUNE 3, 2022 (Friday)

8:00 AM to 10:00 AM
East Avenue Medical Center (via Zoom Teleconferencing)

Presenter:
John Christopher V. Ruiz, MD
Year Level II Adult Neurology

Moderator:
Russell Anne Marie L. Carandang, MD
Year Level IV Adult Neurology
OBJECTIVES:
1.To present a case of a 28-year old female who came in with left sided hemiparesis
2.To review the clinicopathology, radiologic and differential diagnosis and treatment of patients
considered Stroke in The Young with Systemic Lupus Erythematosus
3.To enumerate the work-up requested for Stroke in the young
4.To discuss the neurologic prognosis and long- term goals for patients considered Stroke in The
Young with Systemic Lupus Erythematosus

DEMOGRAPHIC DATA:
RB is a 28-year-old, female, right-handed, Married, Filipino, Catholic, from Caloocan City, who
was admitted for the first time in our institution last April 26, 2022.

CHIEF COMPLAINT:
Left Sided Weakness

HISTORY OF PRESENT ILLNESS:

(April 23 3:00AM ) 2 days prior to admission, exactly 66 hours prior to admission, patient was
awakened still no presentation of unilateral weakness, patient was still able to pee. Upon waking
up at around 8 am, while having morning talks with her husband they both noted slurring of
speech and weakness of the left side of the body of equal distribution face, arm and leg. Unable to
grab cellphone, not able to walk described as dragging the left side, not able to turn to the left side.
Patient was still able to speak comprehensibly, and was still able to move but opted to lie down in
bed. There was no noted dysphagia . There were no noted aggravating or alleviating factors

(April 23 10:00AM) 59 hours prior to admission, patient was then rushed to a nearby hospital
( Caloocan City Medical Center) and was done Cranial CT Scan showing an infarct. Patient was
advised admission however patient and relative refused because was not allowed to go out once
admitted, hence opted to be discharged against medical advise. Patient recalled Blood pressure
taken was only at 90/ 60mmHg and was given Aspirin, Clopidogrel and Atorvastatin as take home
medications
(April 24 8:00AM) 37 hours prior to admission,upon waking up patient now noted progression of
the severity of slurring of speech, noted to be incomprehensible in nature. Weakness of the left
side of the body also progressed described as heavy, associated with pinching pain. Patient was
now unable to move the entire left side of the body. Still there was no noted dysphagia.

(April 24 7:00PM) 26 hours prior to admission, patient tried to seek consult at Jose Reyes,
however was advised no vacancy available at their institution
During the interim, symptoms there was no noted progression or regression of symptoms

(April 25 9:00- 10:00PM) On the day of admission 9-10PM, patient still had slurring of speech,
noted to be incomprehensible in nature. Weakness of the left side of the body with inability to
move the entire left side of the body. Still there was no noted dysphagia. This was the only vacant
time slot available for their driver, hence consult to our institution.
REVIEW OF SYSTEMS:

GENERAL (-) Easy fatigability, (-) Fever, (-) Loss of appetite, (-) Weight loss, (-)
Malar Rash
(+) Rashes bilateral Legs (Erythematous and macular)- started
November 2021
HEAD AND NECK (-) Nasal congestion, (-) Otalgia, (-) Otorrhea, (-) Neck enlargement,
(-) photosensitivity (-) Carotid Bruits
CHEST AND LUNGS (-) Cough, (-) Dyspnea, (-) Pleurisy
CARDIAC (-) Chest pain, (-) Exertional Dyspnea, (-) Palpitations,
(-) Orthopnea
ENDOCRINE (-) Heat/cold intolerance, (-) Polyuria, Polydipsia, and Polyphagia
GASTROINTESTINAL (-) Abdominal pain, (-) Bleeding
GENITOURINARY (-) Dysuria, (-) Hematuria, (-)Nocturia
REPRODUCTIVE (-) Abnormal vaginal discharges, (-) Bleeding
MUSCULOSKELETAL (-) Joint malalignments, (-) Muscle pains, (+) Arthralgia Bilateral
Knees, erythema - Started August 2021
PSYCHIATRIC (-) Behavioral changes

PAST MEDICAL HISTORY:

Gouty Arthritis, Diagnosed at a Local Clinic (August 2021)

-Patient presented with erythema and swelling of the knees, elbows,joints of the toes and hands.
This was noted to occur for about three times per month and was partially relieved by Etoricoxib.
- Given Etoricoxib 60mg/tab once a day as needed for pain and 1 unrecalled medicine
Total Etoricoxib tablets taken since August were only 4

Sepsis (?), Diagnosed at a Local Clinic (November - December 2021)

- Patient presented with erythema althroughout the body with progression cephalocaudal in nature
- Given unrecalled antibiotics which was Injected once and given steroids once a day for 1 month
which temporarily resolved the erythema all throughout the body

OB-GYNECOLOGY HISTORY:
Patient has a regular menstruation prior to occurrence of the flares; occurring every 28 days,
lasting for 5days, 6 pads per day, noted dysmenorrhea on some menstruation
Patient is a G2P2 (2002)
(Fabella Hospital, 2013)- Term, Cephalic delivered via Spontaneous Delivery
(Fabella Hospital, 2014)- Term, Cephalic delivered via Spontaneous Delivery
Coitrarche at 17 y.o. with a total of 4 sexual partners, no noted STDs
Contraceptives: Implant (2014)
No immunization for HPV
FAMILY HISTORY:

No history of cancer, diabetes, hypertension, or stroke in the family.

No relative with similar symptoms. No relatives with stroke in the young. No known relative with
autoimmune disorder.

PERSONAL AND SOCIAL HISTORY:

Online Selling (2016- 2021)
Nail Tech (2021- 2022)
This was described as Home- based, patient is being called for service
Patient is a High School Graduate of Caloocan High School. Patient is currently living with her
husband and husband’s relative in their Condo Unit at Valenzuela City
Currently, patient denies smoking, alcoholic intake and use of herbal and illicit drugs. Previously
4 years ago, patient had 10 sticks of cigarette per day for 1 year and was a chronic alcoholic
drinker, 1 case of red horse per day for 1 year.
There was no history of exposure to toxic chemicals, doves, or cats and other pets.

PHYSICAL EXAMINATION:

Vital Signs: BP – 100/70 mmHg, CR – 106 bpm, RR – 19 cpm, Temperature – 36.6 C,

Height – 165.1cm, Weight – 65 kg BMI 23.89 - Normal Weight

The patient was awake and not in cardiopulmonary distress.For the general observation of the
patient, the skin examination showed erythematous macular lesion with well define borders at the
legs of the patient. Eye examination revealed an anicteric sclerae with pinkish palpebral
conjunctivae. There was no neck vein engorgement on inspection and no lymphadenopathies on
palpation. There were no noted carotid bruits. No masses, tenderness, or nipple discharges
observed during breast examination. The chest was symmetric with clear breath sounds on
auscultation. The chest had an adynamic precordium with normal cardiac rate and regular rhythm.
No cardiac murmurs heard. The abdomen was soft, with normoactive bowel sounds. There was no
edema seen on all extremities. The peripheral pulses were good and palpable.

Neurologic Examination:

I. MENTAL STATUS EXAMINATION & HIGHER CORTICAL FUNCTION

The patient was mesomorphic, well-kempt, and wore appropriate clothing. Speech was severely
dysarthric, normal flow, formal tone and normoproductive. The patient was silent and calm during
the interview and displayed a broad affect. No signs of agitation or emotional lability. Illusions,
hallucinations, delusions, and misinterpretations were not observed. The patient was of average
intellectual capacity. The patient was awake, normal attention span. She was able to spell the word
MUNDO and spell it backwards. She was oriented to person, time, and place. Intact recent and
remote memory. Good immediate memory recall. Fund of information, insight, judgment,
planning, and calculation were not properly assessed. Absence of glabellar tap, palmar grasp
reflex, rooting reflex, sucking, or palmomental reflex responses were observed.

The patient was able to identify watch, pen, and cup correctly. She was able to repeat the phrase,
“No and, ifs, or buts”. She was able to write a complete sentence and copy the figure with
interconnecting lines. She was able to draw the shape of the clock. She was able to button her
dress correctly. She was able to say “hinlalaki” when asked to name the right thumb. She was able
to differentiate right and left. She was able to show how to brush her hair correctly. She was able
to tell step by step on how to cook rice. She was only able to roll back and forth the key when
asked to identify it when it was placed on her palms on the unaffected and affected side while her
eyes were closed. She was able to identify the single digit, circle and square shape written on both
her palms. She correctly identified on which side the examiner was touching her while her eyes
were closed.

II. CRANIAL NERVE EXAMINATION

CN I: Able to distinguish coffee on both nostrils while eyes were closed.

CN II: Visual acuity:20/100 OD 20/70 OS via Pocket Snellen Chart; 20/20, both eyes with use of
corrective glasses.

CN II, III: The pupillary sizes were 3 mm in size, equally round and briskly reactive to light and
accommodation. Patient has intact direct and indirect light reflex. There were no visual field
defects on confrontation testing and finger counting. Fundoscopic findings included presence of
red-orange reflex on both eyes. With prominent vessels and distinct disc margin, present venous
pulsation on both eyes. No AV nicking, cotton wool exudates, or subhyaloid hemorrhages.

CN III, IV, VI: Primary gaze was at midline with EOMS full on visual tracking.

CN V: There was 100% sensation equally felt on all V1 to V3 distribution upon touch, pain,
vibratory and temperature stimulation. The masseter and temporalis muscles have good tone.

CN VII: The patient was able to smile with shallowing of the left nasolabial fold. She was able to
distinguish sugar and salt on the anterior 2/3 of the tongue.

CN VIII: There was good gross hearing.

CN IX, X: The gag reflex was intact bilaterally with equal palatal elevation.

CN XI: The patient was able to shrug the Right shoulder more than the Left. She was able to turn
her head to sides.

CN XII: The tongue was at midline with no fasciculations or atrophy.

III. MOTOR EXAMINATION

There were no tremors seen on both hands at rest. There were no muscle atrophies and
fasciculations observed. There was good muscle bulk and tone. The extremities were spastic on
passive movement. The motor grade was 1/5 on the left arm and leg and 5/5 on the right
extremities.

IV. REFLEXES

A grade 2 reflex was elicited on bilateral biceps, triceps, brachioradialis, patellar and
Achilles. There was absent Babinski reflex response.

VI. CEREBELLARS

No scanning speech and nystagmus seen. No truncal ataxia, dysmetria, and dysdiadochokinesia on
both right and left. The patient was able to do heel-to-shin test.

VII. SENSORY

The patient was able to sense light touch, pain, and temperature sensation on all extremities and
was graded 100% equally. There was intact position and vibration sense.

VIII. MENINGEAL SIGNS:

The neck was no nuchal rigidity noted when passively moved on all sides. There were no
Brudzinski and Kernig’s signs.

INITIAL WORKING IMPRESSION:

Acute Ischemic Stroke Right Lenticulostriate Arteries probably Vasculitic NIHSS 6; Stroke in The
Young; T/c Autoimmune SLE

COURSE IN THE WARDS:

At the ER, patient was venoclysed with Plain NSS at 80 cc/hour. Ancillary procedures were done.
Patient was then started with Aspirin and clopidogrel, Paracetamol, Lactulose and Omeprazole.
Patient was swabbed for COVID19 RTPCR which resulted negative, hence, was admitted to a
non-covid ward.
On the 1st to 2nd hospital day there was already noted improvement of the left sided hemiparesis,
grading motor strength to 3/5. The patient was requested for ANA, RF, ESR and was planned to
be referred to the Department of Rheumatology.
On the 3rd to 10th hospital day, patient had sessions of Physical Therapy and speech therapy with
noted improvement of motor strength to 4+/5 on the left side and better vocalization of speech.
Patient was also preparing funds for autoimmune workup.
On the 11th hospital day, saw the patient and was diagnosed with SLE with the following attributes
1) Immunologic 2) Neuropsychiatric 3) To Consider Renal 4) Rule out Hematologic Problem.
Patient was the requested for Urine Protein Creatinine Ratio, C3 levels, Repeat laboratories for
electrolytes CBC, Bun, Creatinine, Coomb’s Test, ESR, SGPT, SGOT, peripheral blood smear
were requested and work up for APAS was requested. Patient was the started to Hydrocortisone
100mg/ IV Q12, Hydrochloroquine 200mg/IV OD, Calcium + Vitamin D 1 tab OD and Etoricoxib
was put on hold.
On the 12th to 15th Hospital Day, patient was subjected for Pulse Therapy of Methylprednisolone
sodium succinate 100mg in 250cc PNSS to run for 4-6 hours Every 24 hours for 3 doses.
Monitoring of Vital signs while doing pulse therapy was increased Q15 on first hours and Q30 on
second hours.
16th to 17th Hospital Day, patient’s Blood pressured was controlled to 120-130/80-90 and was then
sent home.

FINAL DIAGNOSIS:
Subacute Ischemic Stroke Right Lenticulostriate Arteries probably Vasculitic NIHSS 6; Stroke in
The Young; Autoimmune SLE

LABORATORY AND DIAGNOSTIC WORK UP:

CBC with Platelet

Date WBC Hgb Hct Neu Lymp Mono Eos Baso Plt BT
4/25/2022 6 0.93 29 81 13 5 0 0 395 O+
5/6/2022 5 92 29 86 11 3 0 0 291
5/7/2022 4 84 27 84 13 3 0 0 284
5/10/2022 8 89 28 83 14 3 0 0 420

Blood Chemistry
Date Crea BUN Na K Cl Ca Mg Phos AST ALT Albumin
4/25/2022 52.5 4.2 138.6 4.03 103.3 1.25 1.25 56 15
5/6/2022 46.2 3.1 137.1 3.37 103.1 46 9
5/7/2022 43.4 2.4 137.60 3.55 42 9
5/10/2022 41.20 5.4 137.1 3.97 107.6 28 14 23

Auto Immune Workup

Date ESR ANA Anti- ds- DNA
5/6/2022 116 >32 ratio 32 IU/ml

Urine Protein Creatinine Ratio

Date Creatinine (Urine) Urine Total Protein Urine Total Protein- Creatinine Ratio
5/7/2022 30.97 mg/dl 0.024gm/dL 774.943mg/g

Bilirubin
Date TB DB IB
5/7/2022 11.05 4.3 6.75
 Coagulation Factors
Date PT Control INR %act PTT Control
4/25/2022 11 12.2 0.87 118.5 26.2 31.5

FBS and Lipid Profile

Date FBS Total Chol HDL LDL VLDL Triglycerides
5/8/2022 6.72 3.84 0.44 2.30 1.10 2.42

Urinalysis

Date Color Transpa pH Specific RBC WBC Epithelial Mucus

rency Gravity Cells Threads
4/26/2022 Dark Turbid 6.0 1.030 1-3 Over 50 Moderate Few
Yellow
Bacteria Glucose Protein Blood Ketones Nitrite Bilirubin
Few Neg Neg Neg Neg Neg Neg
5/6/2022 Yellow Slightly 7.0 1.015 0-1 1-2 Few Few
Cloudy
Bacteria Glucose Protein Blood Ketones Nitrite Bilirubin
Few Neg Neg Neg Neg Neg Neg

Chest X-ray
4/25/2022 Chest AP Sitting

Radiologic Findings:

Limited study due to obliquity.

There are no evident parenchymal infiltrates.

The heart is normal in size.
The aorta is unremarkable.
Both hemidiaphragms, costophrenic sulci, and visualized bones are intact.

Impression:
Chest negative.

Plain Cranial CT Scan

4/25/2022 PERTINENT HISTORY: APHASIA AND LEFT SIDED BODY WEAKNESS
PLAIN CT SCAN OF THE HEAD
Multiple contiguous axial images of the head were obtained without intravenous
contrast.
There are hypodense foci seen in the left thalamus and right basal ganglia. The
 parenchymal gray-white interface is normal.
The ventricles, cisterns and sulci are normal in size and shape. There is no midline
shift, mass or mass effect.
There is pneumatization of both middle turbinates. The mastoid air cells and
paranasal sinuses are well aerated. The visualized osseous structures are
unremarkable.
IMPRESSION:
Acute infarcts, left thalamus and right basal ganglia.
Concha bullosa, both middle turbinates.

OPS/NPS RTPCR TEST FOR COVID 19

4/28/2022 Negative