A 25 year old woman brought to hospital with
chief complaints of
Fever since 4 days
Unable to talk since 3hrs
Unable to swallow since 3hrs
Deviation of mouth to left since 3hrs
Informant: Husband & Mother
History of presenting illness:
Patient was apparently alright till 4 days back
then complaints started as
- Tooth ache associated with Fever which is of
low grade, intermittent, lasts for 1 day.
- Patient went to dentist and took treatment and
fever relieved on medication and no fever for 2
days duration.
- Again fever recurred since 9hrs prior to
admission(on day4), which is high grade,
continuous, associated with chills and rigors
- C/O inability to talk, but able to understand
commands since 3hrs duration.
- C/O difficulty in swallowing since 3hrs
- C/O deviation of mouth to left since 3hrs
- No c/o weakness of limbs/ paraesthesias of
limbs/ loss of consciousness
- No c/o involuntary movements of limbs/
frothing from mouth/ tongue bite/ uprolling of
eyeballs/ staring look.
- No c/o involuntary micturition/ defecation
- C/O urinary urgency since 3 days
- C/O shortness of breath which is exertional
iniatially , now of grade III since 2 months.
- No c/o orthopnea/ PND/ chest pain/
palpitations/ pedal edema/
- C/O easy fatiguability since 2 months
- No h/o cold/cough/vomitings/loose stools/
abdominal pain/constipation
- No c/o rash over the body
- C/O bleeding per rectum intermittently since 2
years diagnosed as hemorrhoids previously
Past history :
No h/o similar complaints in the past .
K/C/O Anemia since 1 yr
No h/o DM/HTN/TB/ Bronchial Asthma/
Epilepsy/ CAD/CVD/Renal problems/Thyroid
disorders
No h/o blood transfusions in the past.
Family history:
No h/o similar complaints in the family
Menstrual history:
Age at menarche – 13 yrs
cycles are regular 5/30, menorrhagia in the last
2 cycles
Obstetric history: P2L2
1st child- LSCS, boy , healthy , present age: 8yrs
2nd child-LSCS, boy, healthy, present age: 6yrs
Tubectomy done 6 yrs back
Personal history :
Takes mixed diet
Bowel & Bladder habits are regular
Sleep & Appetite are normal
No addictions
Drug history:
patient is not using any medication prior to
present illness.
General condition on examination:
Patient is conscious, coherent
Pallor++, pale tongue, pale nails+
Venous hum +
No icterus/ cyanosis/ clubbing/ lymphadenopathy/
pedal edema
Dental caries+
Painful opening of mouth+
Vitals:
Temperature : 100 F
Pulse : 98bpm, regular, hyperkinetic, no radio-radial
delay, no radiofemoral delay, All periperal pulses are
palpable
BP: Supine : 110/70 mmHg
Standing : 110/70 mmHg
RR: 18cpm
SpO2: 100% on RA
CVS: S1, S2 normally heard, tachycardia +
RS: B/L NVBS+
P/A : soft, no tenderness, no organomegaly
CNS: GCS : E4V1M6 , Pupils: b/l NSRL
Higher mental functions:
speech – Aphasia+ , comprehension – normal
Motor Aphasia
Cranial nerves:
FACIAL NERVE RIGHT LEFT
FROWNING Absent present
WRINKLING Absent present
CLOSURE OF EYES Unable to close normal
completely
NASOLABIAL FOLD Lost normal
DEVIATION OF MOUTH To LEFT
IX, X cranial nerves:
Right palatal arch is lower compared to left
Gag reflex- absent both sides
No phonation
Motor system :
Bulk – normal and equal in b/l upper & lower limbs
Tone : normal in 4 limbs
Power : right left
UL 4-/5 5/5
LL 4+/5 5/5
Reflexes : B T S K A
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
Plantars : B/L Flexors
Sensory : decreased pain & touch of right upper limb
Cerebellum:
B/l Finger-nose test , diadochokinesia – normal
No signs of meningeal irritation
Gait- normal
Provisional Diagnosis:
Acute post viral demyelinating lower cranial
nerve palsy(right VII, b/l IX,X )
? Gullian Barre Syndrome variant
? Stroke in young (r/o hypercoagulable state)
With Severe Anemia
? Secondary to hemorrhoids
INVESTIGATIONS:
Treatment given:
In view of Hb: 3.8gm% , 1 unit of packed RBCs
transfused
Day 1:
Fundus examination : pale fundus
ENT referral done in view of Dysphagia :
advised VDL
Day 2 :
Post transfusion Hb: 6.5gm%
Platelets : 21000/cumm
Stool for occult blood : positive
1 unit of SDP transfused
ENT Review :
VDL – within normal limits
Advised barium swallow
Fundus : pale fundus
PERIPHERAL SMEAR (Bed side ) :
Few Myeloblasts are seen
One lymphoblast is seen
Few platelets present
Suspected Acute Leukemia
Day 3:
Patient made sounds GCS: E4V2M5
C/O Weakness of right upper and lower limbs
Fundus bedside :
right eye : Rothspots + in superonasal quadrant
left eye : segmental dysfunction of arterial tree
peridistal flame shaped hemorrhages
In view of Hb: 4.5 gm%
Platelets : 20000/cumm
1 unit of Packed RBCs and 4 units of RDPs
transfused
BONE MARROW ASPIRATE :
Erythroid series : decreased in number with
predominantly late normoblasts
Myeloid series : Granular promyelocytes . Some show
AUER rods . Also myeloblasts with multiple nucleoli
are seen
Megakaryocytic series: markedly decreased in number
Myeloid : erythroid ratio :: 90:10
Myeloblasts : 20%
Granular promyelocytes : 70%
Opinion : ACUTE PROMYELOCYTIC LEUKEMIA M3 -
HYPERGRANULAR VARIANT
MRI BRAIN :
Acute Left MCA territory infarcts, these are
patchy, embolic in nature. Small right MCA
infarct too involving the cortex
FINAL DIAGNOSIS :
ACUTE PROMYELOCYTIC LEUKEMIA (M3) with
RIGHT HEMIPARESIS with CRANIAL NERVE
PALSY (VII,IX,X) with bilateral ACUTE MCA-
ACA INFARCTS.
