Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Cerebral mass effect, Computerised tomogram abdomen normal, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Demyelination
Clinical narrative: I performed this clinical encounter by utilizing a real-time telehealth video connection between my home and the patient's location which was determined to be at rehab center. I obtained a verbal consent from the patient to perform this clinical encounter using the video and prepared the patient answering and questions they had about the telemedicine interaction. The interaction was facilitated by the staff at the rehabilitation center, as well as the family member.  The patient comes to the center today, referred by email by MD, one of our neurooncologists, as she had been consulted about what looked like a brain tumor on imagining, but by biopsy turned out t0 be a fulminant demyelinating event.   The patient is a 37-year-old woman with no prior neurologic history including no headaches. She got her Johnson & Johnson early May she had more a severe left frontal headache, prompting her to go to emergency department, where they diagnosed migraine headache and sent her out. There was no focal weakness, no generalized weakness. No focal visual loss but some "flashing lights". No speech difficulties. She quickly came back because the headache got more severe, and head CT 5/5/21 showed a right frontal lobe area of vasogenic edema with left midline shift, raising concern for tumor or abscess. She was transferred to Health Center where she was from 5/4/2021 to 5/13/2021.  Here an MRI Brain on 5/5/21 showed a right frontal lobe mass lesion, with left midline shift, with increased signal on T2 and flair, with some wispy enhancement, microhemorrhage, and the size was 6 x 5 x 5 mm. no other brain lesions.  Because of the concern for tumor doctor did a brain biopsy 5/7/2021, which showed hypocellularity of the white matter with gliosis, scattered atypical cells, macrophages, perivascular demyelination, perivascular ring hemorrhages, but no infectious agent with extensive investigation. Pathologic diagnosis was acute hemorrhagic leukoencephalitis, or also mentioned was Weston hurst disease.   In hospital she got IV Decadron 10 mg initially with Keppra also prophylaxis, and 4 more days got IV Decadron 4 mg every 6 hours. After that she went to 4 mg p.o. twice daily of dexamethasone, and was discharged for the last 2 weeks on dexamethasone 2 mg p.o. twice daily.  This helped her to "get better", with no more headaches or sweats or dizziness, and her generalized weakness did get better. She was transferred to rehabilitation where she is now back for 2 weeks and getting stronger and they are "working on her speech". It is anticipated she will leave rehabilitation sometime later this week.  Other work-up at Medical Center included repeat head CT and MRI brain 5/8/2021 that showed the biopsy site with no complications and again no other lesions in her brain. CT of the chest, abdomen, pelvis, were unremarkable. Basic blood work unremarkable.  Past medical history is unremarkable other than cesarean section pregnancy deliveries.   Medications: Birth control pill, dexamethasone 2 mg p.o. twice daily as above for the last 2 weeks, calcium, gabapentin 100 mg p.o. 3 times daily for right leg pain, Keppra 750 mg p.o. twice daily for seizure prophylaxis, Protonix.  Family history unremarkable for MS or other inflammatory conditions.  Social history she works in a factory, and wonders about when she go back to work.  Review of systems otherwise noncontributory.  No objective data generated during this video visit.  Assessment and plan: Acute fulminant inflammatory demyelinating lesion, biopsy-proven, suggesting the possibility of tumefactive onset of MS. No other lesions however present at teh time and no infectious agents found in the biopsy area. She really has had a fairly non-focal presentation, and IV corticosteroid settled down the nonspecific symptoms and she is already on track and finishing rehabilitation soon.  I propose that we do a slow dexamethasone taper, by consolidating the dexamethasone to 4 mg orally once a day for 2 more weeks, then decrease to 2 mg p.o. orally once a day until I see her back.  We will also get a repeat MRI of the brain about a month after the last one was done, so early June, to compare to the 2 in particular from 5/5/2021. This will be to make sure the lesion is settled down not getting bigger suggestive of tumor and perhaps scarring down already, and that there is no new inflammatory areas involving that would get us closer to a pattern of recurring demyelination and raise more concern for MS.  This was in temporal proximity to a Johnson & Johnson Covid vaccine, so may represent autoimmune over reaction to the vaccine. On that basis it could be a one-time never reoccurring event, so I do not think we need to get into doing any kind of more aggressive anti-inflammatory therapy with things like Ocrevus or chemotherapy agaents, unless we start to see a pattern of ongoing semyelination.  I will see her back in 4 to 6 weeks in clinic, in person, and at that point we will also with results of MRI brain done.  Approximately 66 minutes were spent with the patient of which more than 50% was counseling coordinating care on 5/26/2021. Patient understood and agreed with the plan of care outlined.   The patient returns to the Medical Center today, in person, in follow-up for her right frontal lobe inflammatory demyelinating tumefactive lesion that had been surgically resected and that was the pathology as opposed to tumor. She is on a slow tapering course of dexamethasone, and was a the neurosurgical offices prior to this visit today. They are planning to wean her off the dexamethasone over the next 3 weeks or so.  her right frontal head pains are overall better and the sutures above the area of the surgical resections is looking good. She also has a more generalized headache left more than right. Otherwise though there is not focal new deficits though there never was a prominent focality to it. She specifically denies any focal weakness or numbness or vertigo or dizziness. No leg dragging. No seizures on her current dose of Keppra.  Medications: Dexamethasone currently a 4 mg p.o. 3 times daily and that plan for another week, then twice daily for a week, then once a day for a week, then off. Docusate/senna, enoxaparin, birth control, gabapentin 100 mg p.o. twice daily, hydrocodone/APA 5/325 every 4 hours as needed pain, Keppra 750 mg p.o. twice daily, pantoprazole, MiraLAX for constipation.  Exam blood pressure 120/70, pulse 94 and regular. She has a right frontal scalp incision, that is healing well. No drainage. Extraocular movements are full without nystagmus. Fave moves symmetrically. On sustention no pronator drift. Strength 5 out of 5 throughout both legs detail. Gait normal. Finger-nose testing no dysmetria. This event occurred soon after a Johnson & Johnson Covid vaccine, so we will have to report this to the website for vaccine complications.  She has been out of work on a note until today, and I will give her a new note faxed to office putting her out of work until 10/01/2021.  She did get a repeat MRI of the brain under my order on 6/1/2021 and that was compared to the one from 5/8/2021 and the one from 5/5/2021, that were after the biopsy to assess the site. The report was some persistent enhancement around the right frontal cavity where the resection was done, and by indirect inference I assumed no new lesions and when I look at the actual images from 6/1/2021 I do not see any other inflammatory demyelinating lesions so this is good news. The review of these images was complicated by the fact that her identification on chart reads one this but disc reads another so we will have to get the chart changed.  Impression and plan: I spent 37 min of which more than 50% was counseling and coordinating care regarding her right frontal inflammatory demyelinating tumefactive lesions, that was resected and looks like it was settling down. On repeat MRI of the brain just done earlier this month there is no new lesions occurring which is also good new that this may just be a one-time complication of the Johnson & Johnson vaccine, as long she does not get another Johnson & Johnson vaccine, there should not be a recurrence of the demyelinating events or a move towards more typical multiple sclerosis.   We will get a repeat MRI the brain in December 2021 to compare to the previous ones and again make sure nothing is happening subclinically. If a new clinical event occurs before then we might move that MRI up.  She should stay on Keppra seizure prophylaxis.    Again I put her out of work until 10/01/2021 as above. She works at a meat processing factory. She clearly cannot currently work in the hot conditions and clearly is physically and cognitively not able to do this job at the present time. We did set up a visit in 3 months, to see how she is doing and will get the MRI of the brain 3 months after that.