Age: 13.0
Sex: M
Vaccine: HPV4
Symptoms: Angiogram cerebral normal, Blindness, Breath sounds abnormal, C-reactive protein increased, Cerebral infarction
Clinical narrative: This is a 13 yo male with cortical infarct, left-sided arm weakness, and new onset seizure. Patient was fine when he went to sleep on 8/19.  He woke up on 8/20 and complained of tingling in his left (dominant) arm.  He felt that he could not operate it normally.  He also felt that "his brain was hurting" and that it was not a usual headache.  He probably did not have any weakness at the time.  The headache continued.  Around 4:30 pm he was sitting with his siblings in the living room.  He stood up and took a few steps and then collapsed.  He told me that he remembered that his left arm stiffening and then the "bones in the left arm start to shake" and had complete loss of vision.  That is the last thing that he remembers. According to his sister who witnessed the episode, he had a generalized convulsion and was making noisy breathing sounds.  It lasted "6 minutes."  Patient was able to talk upon waking up, but was claiming that he could not move his body below his neck.  Strength gradually returned to his right arm and his legs.  He was carried to the ambulance and was brought to Hospital.  He was there for no more than 2 hours.  His vitals were stable and he was sent home with a diagnosis of "new onset seizure" and "Todd's paralysis."  He had a CT scan of the brain which was normal. His weakness continued.  The following day, he still could not move his left side.  He appeared like he was going to fall to the left.  His mother gave him some Motrin that brought some improvement.  He continued to complain of  "pain in the brain."  He did not vomit.  Patient continued to have weakness throughout the day and complained that "I cannot feel my face."  The mother then decided to bring him to another Hospital emergency room. On admission to Hospital emergency room, BP 132/82, HR 116, T 39.3, RR 20, O2 sat 100% on room air.  His examination did not reveal a source of a fever.  He had obvious left arm weakness.  A CMP was completely normal including liver enzymes.  CBC showed white count 5.56, hemoglobin 14.4, hematocrit 42.2, MCV 75.9, platelet count 316, CRP 31.  After treatment with antipyretics, his temperature went down to 37.4, and the blood pressure went down to 105/71. Angiogram of the brain was completely normal.  MR venogram showed some development of asymmetry of the transverse and sigmoid sinuses.  There was no evidence for thrombosis.  MRI showed a small area of restrictive diffusion in the right precentral gyrus sitting exactly on the motor strip in the area that fits the shoulder and the arms.  There was no enhancement seen.  The findings were compatible with a diagnosis of cortical infarct.  There was no associated hemorrhage. There was a significant weakness, 2/5, of the left arm.  He was able to wiggle his fingers.  However, he was not able to resist with his fingers.  He reported somewhat decreased temperature sensation and an almost normal vibration sensation in the upper extremities.  Reflexes were not increased.  There was mild weakness of the angle of the mouth on the left compared to the right when I asked him to forcefully smile.  There was no difference in the eye closure.  The tongue was midline. IMPRESSION:  We have a very unusual picture here.  We have a small area of cortical infarct without any effect on the subcortical white matter.  We do not have any personal or family history of increased coagulation.  He comes from a very large family on his mother's side.  His sister may have an autoimmune disease.  The seizure is somewhat unusual.  We typically see seizures at the onset of the stroke.  Here, patient had symptoms since the morning the seizure occurred at 4:30.  The seizure makes the situation even more perplexing here. Whatever diagnosis we will come up with here is extremely unusual.  Trying to put everything together, one may think about an autoimmune disease such as cerebral vasculitis or infection associated increased thrombosis.  However, we do not have any evidence, so far, for systemic involvement of any sort.  He does not appear to be neurologically sick as patients with cerebral vasculitis.