23 y/o under parapesis diagnosed with cerebellar atrophy associated with Phenytoin toxicity

Note : This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. 

I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

June 26 2021

Case recorded from Summer 2021.

(Under the guidance of  Dr.Chandana, Medicine PG)

Day 1

CASE : 23 Y/O MALE SUFFERING FROM ? PARAPARESIS, 2° to ?SCD DORSAL COLUMN AND CORTICO SPINAL TRACT INVOLVED AND 2° ? CERVICAL MYELOPATHY

Initial Assessment : A 23 year old male hailing from Telangana, currently staying at home (unemployed).

Chief Complaint : (Recorded in the words of the patient)

1) Difficulty  in standing/walking - since 1 week.

2) Weakness of all 4 limbs - since 1 week

3) Swaying on standing posture - since 1 week

History of Present Illness : (Recorded in the words of the patient)

• Patient was apparently alright 5 years ago, when he was playing carroms with his friends, that's  when he had an episode of LOC associated involuntary movements.
• Patient was taken to the nearby hospital, where they told he had 3 seizure episodes and started him on T.Phenytoin 100 mg/PD/BD.
• Patient used to take the above prescribed medication regularly and used to have episodes of shivering whenever he skipped doses (Patient was aware he was having severe episodes - 3 SPS).
• 6 months ago, patient  went to Hyderabad  for evaluation.  Got EEG and MRI Brain done (Patient lost these reports, so reports not available). They advised to continue the same treatment.
• Since 1 week, patient was having weakness of lower limbs, next day, patient  fell down while attempting to get up from a chair.
• Since then, patient has difficulty in standing, walking.
• H/O difficulty  in squatting and getting up.
• H/O slippage of footwear.
• H/O difficulty in mixing food.
• H/O bad in combing hair, taking food into mouth.
• H/O ingestion of outside food 20 days ago.
• Neck - Able to lift neck above pillow.
• Trunk - Able to roll over bed, but unable to get up from bed.
• No h/o difficulty  in breathing, swallowing. 
• Slurred speech (+) (intermittently 3 episodes, again became normal)
• No h/o paresthesias; numbness; tingling.
• No h/o loss of smell, taste; no blurring of vision and no giddiness.
• No deviation of mouth and tongue.
• No diplopia.
• No loss of sensations over face.
• No involuntary movements.
• No h/o bard like sensations, able to feel clothes (+); able to feel hot and cold water (+).
• No pins and needles sensations.
• No back pain/foot pain.

Day 2

Past History : 

Chest deformity seen -  ? Pectus Excavatum.

Treatment History :

1. Diabetes  - Not present
2. Hypertension  - Not present 
3. CAD - Not present 
4. Asthma - Not present
5. Tuberculosis - Not present 
6. Antibiotics - None used
7. Hormones - None used
8. Chemo/Radiation - Not given 
9. Blood Transfusion- Not given 
10. Surgeries - None
11. Other - None

Personal History :

1. Marital Status- Single 
2. Occupation - Unemployed, stays at home
3. Appetite - Normal
4. Non vegetarian 
5. Bowels - Regular 
6. Micturition - Normal 
7. Known allergies - None
8. Habits/addictions - None

Family History :

1. Diabetes- No
2. Hypertension - No
3. Heart diseases - No
4. Stroke - No
5. Cancers - No
6. Tuberculosis  - No

Physical Examination :

A. General 

1. Pallor - No
2. Icterus - No
3. Cyanosis - No
4. Clubbing of fingers/toes - No
5. Lymphadenopathy - No
6. Oedema of feet - No
7. Malnutrition - No
8. Pulse Rate = 98 beats/min
9. Respiration (count for a full min) Rate = 20 breaths/ min.
10. BP Lt. Arm = 100/70 mm/Hg.
11. SPO2 at Room air 100%
12. GRBS 110 mg%
13. Chest deformity present since birth.

B. Cardio Vascular System

S1, S2 - No murmurs

C. Respiratory System

BAC - (+), NVBS, Left Hemithorax diameter < Right Hemithorax.

D. CNS 

General Examination :

1. Conscious
2. Coherent
3. P I C K L E - Negative 
4. Temperature  - Normal
5. Neurocutaneous markers - Negative

HMF :

1. Consciousness - Present
2. Orientation - Normal
3. Speech - Normal
4. Language  - Normal
5. Memory : Recent - +, Remote - +
6. Delusions - None 
7. Hallucinations  - None

E. Cranial Nerves          

1) Smell - Normal         Right           Left                  
2) Visual Acuity :-        Normal       Normal                                                

• Field of Vision :-  Normal      Normal                        

3,4,6) Extra ocular.       Normal      Normal

              Muscles  :-                            

• Pupil size :-           Normal      Normal                         
• Accommodation.  Normal      Normal     

5) Sensations of face :-  Normal      Normal

• Masseter                Normal       Normal  
• Temporalis            Normal       Normal 
• Pterygoid               Normal        Normal

• Corneal reflex           +                      +                                     
• Conjunctival reflex    +                    +                                     
• Jaw jerk                                    -                         

7) Orbicularis oculi       Normal        Normal

     Orbicularis oris        Normal        Normal                         

8) Rinne's 

     Weber's 

9,10) Uvula - Central, Palatal movements - Normal

11) SCM - Normal

F.Motor

• Bulk :- Same on both sides
• Tone :- Normal in all 4 limbs
• Power :-

      A) Upper Limb

• Shoulder flexion - 4/5 both sides
• Extension - 4/5 both sides
• Elbow - 5/5 both sides
• Hand grip - 80% both sides

       B) Lower Limb

• Hip - 3/5 on both sides
• Knee - 4/5 on both sides
• Ankle - 5/5 on both sides

• Reflexes :-

                                     Right              Left         

1) Superficial  

• Corneal                  +                    +                                    
• Conjunctival         +                    +                                    
• Abdominal            +                    +                                   
• Plantar                 Ext                  -                

2) Deep                       

          B                       3+                                 3+

                                      

          T                       3+                                 3+

                                       

          S                        3+                                3+

                                     

          K                       3+                                 3+

                                    

          A                       2+                                 2+

                  

   Finger flexor         3+                                 3+

   

   Ankle clonus          +                                   +

   (Present on both sides)

G. Sensory

1. Spinothalamic : 

• Crude touch - normal on both sides
• Pain - Normal
• Temperature  - Normal

     2. Posterior Column :

• Fine touch - normal
• Vibration- lost in lower limbs, upper limbs reduced (less than 6 secs)
• Proprioception - lost on both sides
• Rombert's positive
• Cortical : Stereognosis - normal

     3. Cerebellum :

• Nystagmus - present towards left side
• Finger nose, finger finger coordination- present
• Knee heel coordination- present

ANS

1. No postural hypotension 
2. No bowel bladder incontinence 

Provisional Diagnosis :

1. Paraparesis  - reduced on evaluation
2. 2° to ? SCD (Dorsal columnar lateral cortico spinal tract involved)
3. ? Cervical myelopathy (post infection) -compressive

Day 3

• MRI C Spine was done to rule out compressive myelopathy. Report awaited.

Day 4

• Patient had left Hospital 1 to seek a second opinion from a neurologist to Hospital 2 (discharge at request).
• As Phenytoin toxicity is considered, medication was changed to Levipil.
• Patient had 2 episodes of transient loss of speech and slurred speech lasting for about 2 hours.

Day 4

MRI C spine report

Advice 

Serum Phenytoin and MRI Brain was also suggested.

                         Final Diagnosis

CEREBELLAR ATROPHY SECONDARY TO ? PHENYTOIN TOXICITY.