Case of the Week: Transient Neurological Symptoms
A 32 year old female presents with an expressive dysphasia to her GP. Her GP initially thinks it could be migraine as she recalls a mild headache. However, he explains to the patient that she needs to be seen in the hospital for a check up.
She has no visual symptoms, motor symptoms or other neurological symptoms or signs.
By the time she arrives in the Emergency department, her symptoms have entirely resolved.
O/E
Temp 36 o Celsius
BP 112/78
Sats 99% Air
GCS 15/15
Fingerprick Blood glucose 3.9mmol/l
On examination she has an entirely normal neurological examination. The rest of the general examination is unremarkable other than a soft systolic murmur.
Is there anything else to be done, or should she simply see her GP for a follow up and consideration of a referral to a headache clinic? If there is something to be done, what is it and why?
another case of female hysteria
send for the psychiatrist
alteratively send for homeopathy
nothing else to be done
send for a chiropracter
Barndoor neurosyphilis. See half a dozen of these a week, at least.
J
I always refer them to GUM…. hope I’m not mis-managing them in any way….
Close but no cigar Josh although I’m enjoying the logic… sure that systolic murmur fits in?
You are broadly correct in referring them to GUM. Remember if you have one STI you should be screened for the ‘big 3′
Hepatitis B/C
HIV
Chlamydia
You know what – you’re right. The systolic murmur doesn’t fit in, and this is why the Social History is so so important, as well as an accurate drug history.
This woman is 32, and childless. She thinks that being thinner will attract a mate, and this is why she is taking the perilous combination of phentermine and fenfluramine to facilitate rapid weight loss.
The resultant primary pulmonary hypertension is causing the soft systolic murmur due to TR (and perhaps a Graham-Steele murmur as well that wasn’t noticed initially).
The headache is probably due to the sildenafil she is taking to make the artificial insemination methods more enjoyable. Or maybe the clomiphene to get those ageing ovaries working harder.
And the neuro symptoms – well, it’s probably just anxiety about her impending life of barren singleness with only cats for company.
I would prescribe paracetamol (naturally) as well as large regular doses of diazepam to be continued indefinitely, which I believe is the appropriate first line therapy to treat her anxiety.
(yet again, I hope nobody from the GMC is reading this)
Josh
Again Josh that cigar is lit but you’re not quite able to smoke it yet… You’re barking up a tree but its not the right one…
I did enjoy the pulmonary hypertension reference: had you considered that the sildenafil (viagra for our more junior readers) could be part of a clinical trail in its use in the treatment of pulmonary hypertension. Bosantin is more en vouge at the minute I suppose.
All that talk is interesting but its not the diagnosis. Anything else this could be?
Dammit – I’m determined to crack this one! And I’d like to thank you for pointing me in the right direction: the travel history.
Common things are common, after all.
This high-flying investment banker took a career break of 6 months to work overseas in developing countries. There she was regularly eating uncooked meats, leading to her infection with T.Solium and T.Saginatum. (Not to mention her hookworm – that anaemia isn’t just due to menorrhagia, you know).
The resultant neurocysticercosis explains her simple partial seizure and headache, and she sadly has myocardial cysticercosis causing a dilated cardiomopathy, with resultant MR.
I think the key in managing this case is going to be sensitively informing her of the bad news and uncertain prognosis before slapping her on some steroids and anti-helminthics.
I know some people would go ahead and do bloods, imaging, or muscle biopsies, but I’m pretty confident, as after all 97% of the diagnosis comes from the history and physical examination.
This is bread and butter medicine, probably a couple of these on every take.
Can I smoke that cigar now? (It’s a fat Montecristo, by the way)
Josh
And does Dr Taylor really use an echo the way I use a knife and fork? Cutting and slashing the patient before putting small pieces in his mouth? I have never seen a cardiologist use this technique before – but I presume his images are superior to the conventional methods.
J
And finally the answer!
The expressive dysphasia is a clear indication there is focal neurology. Be extremely cautious about diagnosing a migraine in this situation, although there are Neurologists that describe the so called “hemiplegic migraine”.
But.. There is no headache.
And there is…. A systolic murmur
So….
Systolic murmur
Focal sudden onset neurological symptoms that resolve within 24 hours?
This is a TIA as a result of a paradoxical embolus from the right side of the heart (venous system) to the left side, and subsequently to the brain.
So what should be done?
Echocardiography and a cardiac catheterisation +/- insertion of an umbrella device to close the gap.