Reason for consult: stroke activation for facial weakness, "Likely Bell's palsy" they said.
Story: An 83-year-old right-handed female with known history of T-cell leukemia, hepatitis C, prior ischemic strokes, who presented with headache × 5 weeks and while on the floor, stroke activation was called for new left facial weakness. Stroke navigator (nurse) examined the patient and reported only left facial weakness, likely Bell's palsy. I cancelled activation since she won't be PA candidate. After rounding on my patients, I went to see her to make sure it is just Bell's that won't need stroke workup.
First look at bedside, it is definitely Bell's palsy, however once I started talking with the patient, it turns out to be more than Bell's palsy. Patient reports she has been having persistent headaches over the past 5 weeks, holocranial. About 5 days ago she started to develop hearing impairment in her left ear and yesterday she felt her left side of her face was not moving normal. Today, stroke activation was called for left facial weakness that was deemed lower motor neurone facial and stroke was cancelled.
Pertinent findings on exam:
Exam with left 7th, 8th nerve palsies and weak right superior rectus OD. Normal muscle power in all limbs, normal reflexes with bilateral flexor
plantars.
What are your differentials so far?
Headache, left sensorineural hearing loss then left facial weakness and weak upper rectus have only few differentials.
- Pachymeningeal or leptomeningeal disease causing cranial neuropathy and right upper rectus entrapment
- Mononeuritis multiplex, although it doesn't explain superior rectus muscle weakness
- Left sided Schwannoma or middle ear disease, wouldn't explain weak superior rectus
- Paraneoplastic disease
Next step:
- After I left the patient, leukemic infiltrates was my first differential. I called oncology team to ask if her T-cell leukemia is active or has been controlled.
- Patient was diagnosed with T-cell leukemia after an abnormal CBC in 2017 (WBC 17k). Smear with lymphocytosis and cytometry with clonal CD4 T-cell. T-cell leukemia was confirmed with marrow biopsy. Final diagnosis was asymptomatic T-cell leukemia for observation measures
onlv. - Oncology don't think her leukemia is active, very low suspicion for her symptoms to be related to leukemia.
Workup:
- MRI brain with contrast with no acute lesions but does show diffuse pachymeningeal enhancement.
- CSF was done with 26 WBCs, elevated protein 86 and low glucose 29. Interestingly her meningitis PC panel came positive for HSV1. Oncology were like "I told you, it is not leukemia!"
- This didn't make sense localization wise. HV causes encephalitis rather than meningitis. Encephalitis wouldn't cause cranial neuropathies. Also SF with low glucose, it is either malignant cells or chronic fungal infection.
- I started patient on acyclovir and few days later cytology came with positive malignant lymphocytic cells, cytometry showed CD4 cells consistent with -cell leukemia.
- Now, I called oncology "The patient has leukemic meningitis!"
- HSV can be rarely false positive in cases of latent infection, where the virus stays latent in sensory cells and may circulate in CSF in cases of suppressed immunity although not necessarily causing symptoms.
What happened next?
- Patient progressed quickly. 2 days later, patient developed right sided SNHL, now she lost her hearing completely. One day later, patient tried to get out of the bed, fell and broke her femur neck.
- Oncology felt CNS involvement along with age and comorbidities made the patient not a good candidate for intrathecal chemotherapy. Family elected for hospice.