2nd Article Flashcards
A 19-year-old man was admitted to this hospital
in early spring because of
- otalgia,
- slurred speech, and
- ataxia.
The patient had been well until approximately 1 month before admission, when
- fatigue,
- fever,
- pharyngitis, and
- lymphadenopathy developed.
Twenty-five days before admission, he went to another medical facility, where a test for streptococcal pharyngitis was
negative.
Eight days later, a heterophile antibody test was
positive
the hematocrit, hemoglobin, and blood levels of total protein, albumin, and total and direct bilirubin were
normal; other test results are shown in Table 1.
A diagnosis of infectious mononucleosis due to
Epstein–Barr virus (EBV) infection was made.
Two weeks before admission,
- dysphagia developed and
- pain and
- decreased hearing occurred in the right ear.
On repeat evaluation, a diagnosis of
otitis media was made, and prednisone (45 mg daily, for 5 days) and amoxicillin (for 2 days) were administered, followed by azithromycin (for 3 days).
Eight days before admission, severe
otalgia developed.
On examination by an otolaryngologist, there was
- perforation of the right tympanic membrane, with 2. bloody purulent material in the external ear canal.
for the perforation of the rt. tympanic membrane and bloody purulent material in the external ear canal what med was prescribed?
- Oral cefuroxime (500 mg twice daily) and
2. an otic suspension of topical ciprofloxacin and 3. dexamethasone were prescribed.
Two days later, increasing
unsteadiness developed; the patient fell several times during the next 5 days.
The day before admission, he returned to the otolaryngologist; on examination, there was
an effusion in the right middle ear.
Myringotomy, with fluid aspiration, was performed. After the procedure,
- transient unsteadiness occurred, with vomiting;
- ear pain lessened, and
- hearing partially improved.
After returning home, the patient noted
- slurred speech,
- clumsiness with movements, and
- increasing gait imbalance.
Later that night, he went to the emergency department at another hospital.
Ceftriaxone (1 g) was administered, and he was transferred to the emergency department at this hospital.
The patient reported
- fullness and
- decreased hearing in the right ear,
- weight loss of 4.5 kg, and
- persistent fatigue during the previous month, without neck stiffness, headache, photophobia, changes in vision, tinnitus, vertigo, sensory abnormalities, or difficulty with comprehension.
He had a history of
- acne,
- asthma, and
- otitis media during childhood;
- he had undergone an inguinal herniorrhaphy as an infant.
Medications at home included
a combination of oxycodone and acetaminophen for otalgia and topical benzoyl peroxide.
He had no
known allergies. He attended college. He did not smoke, drink alcohol, or use illicit drugs.
His paternal grandfather had
polymyalgia rheumatica at 75 years of age and a stroke at 80 years of age; there was no other family history of neurologic or rheumatologic diseases.
On examination, the patient was
- thin,
- alert, and
- oriented, with an appropriate affect.
The vital signs and oxygen saturation were normal. The right tympanic membrane was
perforated, with dried blood in the external canal.
The tonsils were
enlarged (3+) and erythematous.
His speech was
fluent and mildly dysarthric.
Extraocular movements revealed
- slight saccadic undershoot,
- normal pursuit, and no nystagmus.
- Hearing (comprehension of whispered words) was slightly diminished in the right ear.
He had
- dysmetria bilaterally on finger-to-nose testing, with
- end-point tremor;
- rapid alternating movements were irregular, and there was
- overshooting bilaterally when the patient attempted to follow the rapid finger movements of the examiner.
Heel-to-shin testing was
intact,
but there was marked
truncal ataxia with standing and walking.
The remainder of the general and neurologic examinations was
normal, including
- repetition and naming,
- strength,
- deep tendon and
- plantar reflexes, and
- sensory examinations.
The hematocrit, hemoglobin level, and platelet count were
normal, as were blood levels of electrolytes, glucose, total protein, albumin, lipase, total and indirect bilirubin, phosphorus, calcium, magnesium, vitamin B12, cholesterol, and lipoproteins.
Results of renal-function tests were
normal; other test results are shown in Table 1.
Dr. Mary E. Cunnane: Computed tomography (CT) of the brain and temporal bones, performed without the administration of contrast material (Fig. 1A and 1B), reveals
- fluid in the right middle ear and mastoid air cells and
2. hemorrhage within the right external auditory canal, findings that are consistent with the recent tympanostomy.
There is no associated
- bony destruction, and
2. both the roof of the middle ear and the roof of the mastoid are intact.
The brain is normal in
appearance.
Magnetic resonance imaging (MRI) of the brain, performed without the administration of gadolinium, reveals
- opacification of the right mastoid air cells and middle ear, as well as
- prominent adenoids and cervical lymph nodes.
No abnormality is evident in the
brain, and the findings are otherwise normal.
Dr. Bogoch: The patient was admitted to the hospital. Results of a lumbar puncture are shown
in Table 1. The oral administration of
cefuroxime (250 mg twice daily) was started by the admitting service.
Dr. Cunnane: On the second day, repeat MRI of the brain with the administration of gadolinium was performed. Images from the MRI scan show
unchanged opacification in the right mastoid air cells and middle ear (Fig. 1C and 1D).
There is
no extra-axial fluid collection, acute infarction, mass lesion or mass effect, or signal abnormality or enhancement in the brain parenchyma.
A magnetic resonance venogram shows
normal flow related enhancement in the dural venous sinuses, without evidence of venous sinus thrombosis or stenosis.
A CT scan of the skull base, obtained after the administration of contrast material, shows
opacification of the right middle ear and mastoid air cells, with no destruction of bony mastoid septa.
The tegmen tympani and tegmen mastoideum are
intact.
Dr. Bogoch: Cefuroxime was
stopped,
after cefuroxime was stopped what meds were given to the pt?
- vancomycin and ceftriaxone were administered intravenously, and
- antihistamines and metoclopramide were also administered. The patient’s symptoms persisted.
On neurologic examination on the fourth hospital day, the patient was
- awake and cooperative
2, but inattentive, with mild anomia and impaired verbal fluency and - verbal working memory.
Comprehension was
normal.
The ability to perform simple arithmetic was
impaired, and
he perseverated when performing the Luria fist-palm-side test of alternating motor sequencing, which is sensitive to
executive dysfunction from lesions of the prefrontal cortex.1
