A 55 year old femlae with headache and visual disturbance

A 55 year old femlae with headache and visual disturbance

1. A 52-year-old Woman with Headache Dr. AL HADI MOHAMMAD MD Phase-A Resident Neurology , Attached to- Olive Unit, Dept. of Rheumatology, BSMMU

2. Particulars of the Patient Mrs. Kulsum Jaman 52 years Homemaker Chandpur Date of Admission and Examination : 04/10/2018

3. Presenting Complaints Exacerbation of Chronic Headache for 05 month Blurring of vision for 05 month

4. Background History J uly 2014 New onset unilateral Headache Blurring of vision

5. Background History Headache - Localized to left temporal region Sudden onset Gradually progressive in intensity Throbbing in nature No radiation Not associated with nausea, vomiting or fever No jaw claudication Partially relieved by taking oral NSAIDs

6. Background History Bilateral Progressive blurring of vision - Insidious onset - Gradually Progressive - Not associated with redness of eye

7. Background History No history of - W eight loss Night sweats Cough Early morning headache

8. Background History CBC - Hb % - 10.0g/dl, ESR- 18mm/1st hour, WBC- 7400/ cmm , Plt .- 2,50,000/ cmm S. Creatinine – 0.8 mg/ dL TSH- 1.89 uIU /mL

9. Background History Treated with Tab. Paracetamol and Tramadol combination twice daily Tab. Naproxen 500 mg twice daily Tab. Quetiapine 25 mg once daily Patient continued these drugs for about 1and 1/2 yr H er symptoms persisted

10. Background History October 2016 She was diagnosed as a case of Giant cell arteritis on the basis of- Headache Temporal artery tenderness (Left) and High ESR

11. Background History CBC Hb % - 9.2g/dl, ESR- 70 mm/1 st Hr , WBC- 7000/ cmm , Plt.-2,70,000/ cmm CRP- 18.2 mg/L RA (Quantitative)- < 11.5 IU/mL

12. Background History Treated with Oral Prednisolone 30mg/day After 1 month of treatment patients condition improved but she developed Iatrogenic Cushing's syndrome evidenced by- Generalized body swelling Pain and weakness in proximal muscles

13. Background History After 1 month Prednisolone was stopped and she was put on to Tab Azathioprine 150mg daily The patient continued Azathioprine for about 1 yr -her headache partially resolved but her visual acuity was gradually diminishing

14. Background History November, 2017 (1 yr after initiation of Azathioprine ) CBC Hb % -10 g/dl, ESR- 113mm /1 st hour, TC/WBC - 7000/ cmm , Plt .- 2,20,000/ cmm CRP- 43.2 mg/L Urine RME- Pus Cells 00-02/HPF, RBC and Cast absent S. Creatinine- 0.80mg/dL

15. Background History November 2017 in BSMMU Treated with- Tab Prednisolone 50mg/day Tab Methotrexate 10mg/week Tab Folic acid 5mg/week

16. Background History Clinical improvement (2 month after new treatment regimen ) Laboratory result (January, 2018) Decrease severity of headache No further progression of visual impairment CBC - Hb.-9.0 g/dl, ESR- 30mm/1 st hour , TC/WBC -10,000/ cmm , Plt .- 2,80,000/ cmm CRP- 4.98 mg/L ANA- 6.10 (negative) Anti CCP- 14 U/mL (negative) MRV- Normal findings

17. Background History By April, 2018- (within 6 months) Prednisolone was gradually tapered to 10mg/day Methotrexate was gradually increased to 20mg/week

18. Background History From May, 2018 to September 2018- on treatment Patients headache deteriorated O ral prednisolone was stopped I ntravenous methyl prednisolone was advised to the patient The patient denied taking intravenous methyl prednisolone however she also stopped taking oral prednisolone for about 1 month Then the patient came to BSMMU neurology department and oral prednisolone was started at a dose of 60mg/day for 7 days The patient was released with oral prednisolone 20mg/day and methotrexate 10mg/week

19. H/O Present Illness Exacerbation of headache Insidious in onset, progressed gradually Increased with exertion initially, then with simple activities of daily living Associated with fatigue, weakness

20. H/O Present Illness Progressive dimness of vision for 5 month

21. Past medical history Hypertensive for 10 yrs. TAH- 10 years back LUCS- 15 yrs. back

22. Immunization History Immunized as per the then EPI schedule Not immunized against HBV, Pneumococcus, Meningococcus, Influenza Virus

23. Family History and Socio-economic History Comes from a lower middle class family Monthly family income is around 20,000 Tk

24. Menstrual and obstetric History Age of menarche : 12 years Surgical Menopause 10 yrs. Back Para 5+0 ALC- 15 yrs. No H/O spontaneous abortion

25. Examination General Examination Appearance- ill-looking, puffy face Build- average, Wt 50kg, Decubitus- on choice Anemia- mild Cyanosis- absent Edema- Bil . pitting ankle edema

26. Examination General Examination Temp.- 99’F Pulse- 84bpm BP- 110/70mmHg, no postural hypotension Respiratory Rate- 18 breaths/min

27. Systemic Examination : CVS Temporal artery pulse- absent bilaterally Other pulses- normal No bruits Precordium-Normal No added sound

28. Musculoskeletal System Gait- normal Spine –normal Arm-normal Leg- normal

29. Examination of Nervous System HPF : Normal GCS : 15/15 Cranial nerves : Pupils - Normal in size Optic nerve : Visual acuity : Rt eye-6/9 aided Lt eye-6/9 Visual field : Intact Colour vision : Normal

30. Examination of Nervous System Ocular movement : Normal Fundoscopy : No abnormality detected Optic disc , Macula, Retinal blood vessels are normal In both eye Nuclear sclerosis (grade 2) cataract in anterior segment of both eye

31. Examination of Nervous System Motor system- Bulk- Normal Tone- Normal Power – 3/5 ( proximal ) 4/5 ( distal) All deep reflexes are intact Plantar response –flexor bilaterally Sensory system- All modalities of sensations are intact

32. Examination of other systems revealed no abnormality

33. Clinical Diagnosis Giant cell arteritis Iatrogenic Cushing's Hypertension Age related cataract (Grade 2)

34. Investigations 22.09.18 CBC Hb.-10.60 g/dl, ESR- 24mm/1 st hour, TC/WBC - 7000/ cmm , Plt .- 2,75,000/ cmm CRP – 25.78 mcg/mL S. ALT-38.69U/L S. C reatinine - 0.80 mg/dL

35. Investigations 07/10/18 BMD- BMD of Lumber 1 st to 4 th vertebrae (AP)- 0.751 gm/cm 2 Equivalent to -2.7 T score Right femoral neck 0.695 gm/cm 2 Equivalent to -2.0 T score Left femoral neck 0.705 gm/cm 2 Equivalent to -1.9 T score Osteoporosis in lumber vertebrae Osteopenia in both femoral neck Basal Cortisol – 141.3 nmol /L

36. Investigations S. calcium- 9.2 mg/ dL S. Electrolytes- Na 139 mmol /L K 3.9 mmol /L Cl 102 mmol /L

37. Ongoing Treatment Tab. Prednisolone 20mg, once daily Tab Methotrexate 10mg once weekly Tab . Folic acid 5mg once weekly Tab Amlodipine 5 mg+Atenolol 25 mg Cap. Omeprazole, 20mg, twice daily Tab C alcium 750mg daily in two divided doses Tab Vitamin D3 1000IU daily

38. Current List of Problems Recent exacerbation of headache Gradual impairment of vision Iatrogenic Cushing's Osteoporosis

39. Thank you