Neurolist Case Study

Speech Difficulty after A Severe Pneumonia

 

38 y/o AAF with history of HTN and recent hospitalization for pneumonia, asthma exacerbation, and bronchitis presents to the ER with episodic word finding difficulty and LOC. Patient states that roughly 3 days prior to the ER presentation, she has noticed episodic word-finding difficulty, with each episode lasting roughly 1 minutes. The day of presentation, pt again noticed difficulty finding words, followed by an episode of loss of consciousness of unknown duration. The LOC was unwitnessed and patient did not know if any seizure like activities has occurred during this episode. Patient denied any bowel or bladder incontinence or tongue laceration but admits to experiencing a period of confusion and incomprehensible speech after regaining consciousness. Patient states that she was recently hospitalized for 3 weeks at an outside hospital for a combination of pneumonia, asthma, and bronchitis and was recently discharged home with a regiment of oral antibiotics, which she has completed. Otherwise, patient denied fever, chill, cough, rhinorrhea, chest pain, dyspnea, nausea, vomiting, diarrhea, weakness, numbness, or tingling. Patient denied any history of seizures or family history of seizures. She also denied any similar episodes in the past. PMH, FH, and Social History are otherwise non-contributory. At the ER, patient was afebrile and vital signs are normal. Physical exam was significant for mild lower face weakness on R. No other focal neurological deficits were found and no speech difficulties, specifically no difficulties with word-finding or fluency, was noted. Laboratory studies were within normal range. CT scan of the head demonstrated area of hypodensity in the L temporal parietal region. 

Because of the abnormality on the CT scan, MRI studies were ordered and patient was admitted for further work up and treatment. The MRI studies later revealed focal lesions around the L temporal parietal region with ring enhancement after gadolinium administration. 

Given the recent pneumonia requiring hospitalization, the concerns are abscess or metastasis due to occult malignancy. Given the prolonged hospitalization for pneumonia, patient was also counseled and consented for HIV screening.  CT scan of thorax, abdomen, and pelvis are ordered in order to rule out malignancy, The result of the CT scan showed diffuse ground glass opacities most prominent in the upper lobe of the lung but no signs of occult malignancy. Transesophageal echocardiogram showed no shunting or valvular vegetation. HIV test, however, was positive with CD4 Lymphocyte count of 33. Given the information, it is felt that the lesion in the temporal parietal region was most likely infectious in origin. Patient was treated for Toxoplasmosis and discharged with follow-up appointment with the HIV clinic. She is also scheduled for repeat MRI in three weeks to evaluate for resolution of the lesion. If the lesion failed to resolved with the treatment for Toxoplasmosis, the possibility of lymphoma will be explored.

This case demonstrated the importance of ruling out infectious process due to immunocompromization as a cause of intracranial lesions seen on imagine studies in patients with suspicious clinical history, even if the patient reports no obvious risk factors.