case 29 - 23M under parapesis diagnosed with cerebellar atrophy associated with Phenytoin toxicity


23 y/o under parapesis diagnosed with cerebellar atrophy associated with Phenytoin toxicity
June 26, 2021
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 :
Diabetes - Not present
Hypertension - Not present 
CAD - Not present 
Asthma - Not present
Tuberculosis - Not present 
Antibiotics - None used
Hormones - None used
Chemo/Radiation - Not given 
Blood Transfusion- Not given 
Surgeries - None
Other - None
Personal History :
Marital Status- Single 
Occupation - Unemployed, stays at home
Appetite - Normal
Non vegetarian 
Bowels - Regular 
Micturition - Normal 
Known allergies - None
Habits/addictions - None
Family History :
Diabetes- No
Hypertension - No
Heart diseases - No
Stroke - No
Cancers - No
Tuberculosis - No

Physical Examination :

A. General 
Pallor - No
Icterus - No
Cyanosis - No
Clubbing of fingers/toes - No
Lymphadenopathy - No
Oedema of feet - No
Malnutrition - No
Pulse Rate = 98 beats/min
Respiration (count for a full min) Rate = 20 breaths/ min.
BP Lt. Arm = 100/70 mm/Hg.
SPO2 at Room air 100%
GRBS 110 mg%
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 :
Conscious
Coherent
P I C K L E - Negative 
Temperature - Normal
Neurocutaneous markers - Negative
HMF :
Consciousness - Present
Orientation - Normal
Speech - Normal
Language - Normal
Memory : Recent - +, Remote - +
Delusions - None 
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
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
No postural hypotension 
No bowel bladder incontinence 

Provisional Diagnosis :
Paraparesis - reduced on evaluation
2° to ? SCD (Dorsal columnar lateral cortico spinal tract involved)
? 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







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