1. UNIT III CASE PRESENTATION – 5 th July 2012 Lweendo Nchimba

2. 11 year old female NM referred from local clinic on 27 th May with c/o  Severe headache (right sided) for 6 wks  Earache for 6 weeks  Double vision for 6 weeks Lweendo Nchimba

3.  No h/o  Fever  Ear discharge  Trauma to the ear  Vomiting  Nausea Lweendo Nchimba

4.  HIV negative  No previous hospital admissions  No h/o TB, HTN or SCD  Given Aspirin (which did not help) from local clinic  No known drug allergies Lweendo Nchimba

5.  Born at term at local clinic; sent home the following morning  No h/o perinatal illnesses  Is in grade 4and hasn’t been to school the whole of the 2 nd term  Under 5 card was not available Lweendo Nchimba

6.  No known Hx of TB household contact, no FHx of HTN, DM, SCD or asthma  Both parents are well  She has 4 living siblings; there is no h/o paediatric death Lweendo Nchimba

7. Mum is a home-maker and dad a bricklayer. Family lives in Chazanga Lweendo Nchimba

8. General condition  Alert  Afebrile  P o J o C o LN o Vitals / anthropometry: temp: 37.2 o C; BP 110/60; wt 25kg Eyes: 6 th nerve palsy right eye Lweendo Nchimba

9. Ears  No obvious lesions, no ear discharge  Otoscopy: Rt ear drum hyperemic Throat: normal Chest: vesicular sounds CVS: S1S2 normal P/A: soft. L o S o Lweendo Nchimba

10. ?Acute Otitis Media Lweendo Nchimba

11. Amoxyl Paracetamol Review A01 5 th June 2012 Lweendo Nchimba

12. Unwell for 2 months: headache, dizziness, double vision and body weakness Headache: right-sided, affects rt ear and eye Double vision worse when looking to the right side Lweendo Nchimba

13. Positive h/o fever No h/o ear discharge,fitting, vomiting, falling or clumsiness PMHx: admitted in Kabwe for current problem and given carbamazepine, diclofenac Lweendo Nchimba

14. Drowsy Crack-pot sign +/- Neck supple Lateral nystagmus No clonus Reflexes normal Head-shin test: + Tandem walk test: + Dysdiadokinesis:+ past-pointing: + Lweendo Nchimba

15.  Space Occupying Lesion ? Infratentorial lesion Lweendo Nchimba

16.  Admit  FBC/DC ESR  U/Es  Dexamethasone  Urgent CT Lweendo Nchimba

17. Patient found sick, photophobic and in much pain Fundoscopy: blurred disk Maintained diagnosis of SOL but also querried Migraine Plan: brustan, morphine and to get CT report Lweendo Nchimba

18. Patient did very well on analgesics The signs of cerebellar lesion were no longer demonstrable while patient was on the ward Pseudotumor cerebri added to the differentials Lweendo Nchimba

19. CT scan revealed normal findings Patient sent home on 8 th June on analgesia and prednisolone. Booked for clinic in 1 week Lweendo Nchimba

20. IndexValue RBC4.53 * 10 9 /L Hb13.4 g/dl HCT39% MCV86 PLT218 RDW12.6% WBC5.26 * 10 9 /L NEUT2.72* 10 9 /L LYMPH1.74* 10 9 /L MONO0.61* 10 9 /L EOSIN0.16* 10 9 /L BASO0.03* 10 9 /L Biochemical test Urea2.77 mmol/L ALT45 U/L AST74 U/L TPROT66 g/L ALB40 g/L TBIL1.9 umol/L Lweendo Nchimba

21. In severe pain, crying, writhing and clutching right temporal area Agitated, not able to examine Readmitted on morphine, Ibuprofen, paracetamol Ophthalmological and ENT evaluations requested Lweendo Nchimba

22. Noted the hx of right sided headache requiring strong analgesics, double-vision, 6 th Nerve palsy and earache O/E – restriction of lateral gaze on the right eye, normal range for the left eye Posterior segment: no disk oedema, normal macula IMPRESSION: Gradenigo’s Syndrome Lweendo Nchimba

23. ADVICE: 1. Continue analgesia 2. Review CT with reference to mastoiditis, rt petrous apicitis 3. Consult ENT 4. Empirical treatment with IV antibiotics Lweendo Nchimba

24. Exam: Both tympanic membranes normal Mucoid secretions right nostril r/o right pansinusitis ADVISE 1. x-ray PNS 2. Audiometry 3. Rev 26 th June Lweendo Nchimba

25.  Left ear – normal hearing  Right ear – low frequency conductive type of hearing loss Lweendo Nchimba

27. Patient febrile Oral cavity – normal rt and lt tympanic membranes normal Nose: congestion with few watery strings – acute rhinitis  ADVICE Repeat CT scan Lweendo Nchimba

28. Meningeal enhancement in middle cranial fossa and supra-sellar cistern; predominantly on the right side No focal lesion in brain parenchyma Sphenoid Sinusitis Lweendo Nchimba

31. 11 yr old female with right sided headache, earache, double vision, abducens nerve palsy DIFFERENTIALS 1. SOL 2. Pseudo-tumor cerebri 3. Gradenigo’s Syndrome 4. Migraine headache Lweendo Nchimba

32. stable: no headache no earache still 6 th nerve palsy (though reducing) fevers trying to settle on morphine and IV antibiotics Lweendo Nchimba

36. THANK YOU Lweendo Nchimba