Age: 14.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Past-pointing, Protein C, Protein C increased, Protein S, Protein total normal
Clinical narrative: Patient is a left-handed 14-year-old young man with auditory processing disorder presenting with 24-hours of new symptoms including: right arm/leg numbness, right arm/leg weakness, altered speech, altered taste sensation, and changes in gait. Neurologic exam is notable for mildly dysarthric speech, right-sided pronator drift, mild right-sided weakness, altered light touch/pinprick sensation on the right, right-sided past-pointing and orbiting, and difficulty with tandem gait.  MR brain was notable for a small left medullary infarct. Etiology of infarct is unclear; possible risk factors include recent COVID vaccination (however, the current data does not support there being a causal link between vaccination and ischemic events) and recent dehydration. Otherwise, patient has no known risk factors, with no recent illnesses, injuries, or other provoking factors.  Patient was admitted to the neurology team for further work up of acute ischemic stroke of the left medial medulla. He was monitored closely with neuro and vital sign checks every 2 hours, which was gradually spaced. There were no new deficits or significant vital sign abnormalities throughout his hospital course.  Clinically, he continued to have significant improvement  in his symptoms throughout his hospital course with minimal deficits (very mild finger extensor and hamstring weakness) on day of discharge, which was >72 hours from his stroke on 6/29. Family met with our Stroke neurology team while inpatient and will follow-up with them when they return home.  He was started on aspirin 81mg daily, which he will continue at home for stroke prophylaxis.  Patient underwent an extensive work-up for cause of ischemic stroke including for cardioembolic, coagulopathy, and intracranial vasculopathy.  Due to motion artifact on MRA, he underwent CTA head and neck. This was reviewed by neuroradiology and neurosurgical colleagues who noted no evidence of malformations or vasculopathy; further evaluation, such as with angiogram, was not recommended based on the quality of the CTA images which were felt to be sufficient. An echocardiogram with bubble was normal; there was no PFO. Extensive hypercoagulability work-up was sent and thus far unrevealing:   Homocysteine- resulted  Factor V Leiden functional - resulted  Protein C functional - resulted  Lupus anticoagulant -resulted  Beta 2 glycoprotein antibodies -pending  Anticardiolipin antibodies   - pending  Prothrombin gene mutation - pending  Lipoprotein a -pending  Von Willebrand factor antigen - pending  NMO - pending (low clinical suspicion)  MOG- pending (low clinical suspicion) Vitamin D - pending  Protein S functional - pending  Antithrombin II functional -pending  Connective tissue disorders were also considered. Funduscopic exam did not show evidence of Lisch nodules; no cafe au lait spots, axillary/inguinal freckles consistent with neurofibromatosis. No skin hyperelasticity or poor wound healing, Beighton score=2 (within normal limits) for mild elbow hyperextension, not consistent with hypermobility syndrome such as Ehlers-Danlos. Hypertelorism but no arterial tortuosity suggestive of Loeys-Dietz syndrome. Long arms relative to height but no other features of Marfan syndrome.  Toxicology was also consulted given many vitamin supplements. After a thorough review, there were no supplements or medications he takes that are associated with ischemic stroke. His toxicology screen was negative for substances. Family was counselled that vitamins are not regulated and therefore, we cannot counsel them regarding absolute safety of resuming the supplements given possibility of unknown additives. However, after a thoughtful discussion of risks and benefits, family has elected to continue them.  He was evaluated by both OT and PT;  while his symptoms have markedly improved we did provide Rx's for outpatient therapies.   No home activity restrictions needed.     Dispo:  Discharge to home with mother.  Follow up has been requested with in the Center as well as hematology/ thrombosis.  He will continue on daily ASA 81mg. Plan for 1mo follow-up MRI/A.  Discharge Physical Exam  Discharge: 1 for RUE drift  General: Awake, cooperative, NAD.  HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx.  Neck: Supple. No nuchal rigidity.  Pulmonary: No increased work of breathing on RA.  Abdomen: Soft, nontender, nondistended.  Skin: No rashes or lesions noted.   Neurologic:  -Mental Status: Alert, oriented x 3. Attentive to interview. Language is fluent with intact comprehension.  -Cranial Nerves:  II, III, IV, VI:  PERRL 3 to 2mm and brisk. EOMI. No longer has nystagmus with R gaze. Normal saccades. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages.  V: Subtle decreased facial sensation over lateral left face  VII: No facial droop, facial musculature symmetric.  VIII: Hearing intact to finger rub bilaterally.  IX, X: Palate elevates symmetrically.  XI: 5/5 strength in trapezii bilaterally.  XII: Tongue protrudes in midline with good excursions. No weakness  -Motor: Normal bulk, tone throughout. Right-sided pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted.    Delt Bic Tri WrE FFl FE FAb IP Quad Ham TA Gastroc EHL  L  5    5   5    5     5    5    5   5    5     5     5     5       5      R  5    5   5   5-    5  5-   5- 5  5-   5-   5     5       5-    -Sensory: Decreased sensation of the right arm and right leg (99% normal) compared to left.  Cold sensation, vibratory sense, proprioception intact throughout. No extinction.  -DTRs:    Bi Tri Brach Pat Ach  L  2   2    2      3   2  R  2   2    2      3   2  Plantar response was flexor bilaterally. No clonus bilaterally.  -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HTS bilaterally. Orbiting noted on right.  -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to toe, heel, and tandem gait. No gait instability     Diagnosis List   1. Ischemic stroke, 06/30/2021  2. Weakness of right leg, 06/30/2021  3. Dysarthria, 06/30/2021  Procedure History  No Procedure History  Social History  Smoking Status      No Smoking Status Documented  No Known Medication Allergies  Labs Last 48 Hours      Event Name  Event Result  Date/Time   Fibrinogen 297 mg/dL 07/01/21  D-Dimer 0.65 mcg/mL FEU High 07/01/21  Von Willebrand Factor Risto Cofactor 124 % 07/01/21  Von Willebrand Factor Antigen 157 % 07/02/21  Von Willebrand Factor Antigen 177 % High 07/01/21  Von Willebrand Factor 8 231 % High 07/01/21  AntiThrombin Functional 74 % Low 07/01/21  Factor V Leiden, Functional 0.96 07/01/21  Protein C Functional 200 % High 07/01/21  Lupus Anticoagulant Screen NEG 07/01/21  Sodium 139 mmol/L 07/02/21  Potassium 4.04 mmol/L 07/02/21  Chloride 104 mmol/L 07/02/21  CO2 27 mmol/L 07/02/21  Anion Gap 8 mmol/L 07/02/21  Glucose Level 95 mg/dL 07/02/21  BUN 11 mg/dL 07/02/21  Creatinine 0.77 mg/dL 07/02/21  Calcium 9.7 mg/dL 07/02/21  Phosphorus 3.7 mg/dL 07/02/21  Magnesium 1.8 mg/dL 07/02/21  AST (Aspartate Aminotransferase) 18 unit/L 07/01/21  ALT 18 unit/L 07/01/21  Alkaline Phosphatase 167 unit/L 07/01/21  B-Type Natriuretic Peptide 17 pg/mL 07/01/21  Albumin 3.8 g/dL 07/01/21  Homocyst(e)ine, Total 3.3 mcmol/L 07/01/21  Total Protein 6.7 g/dL 07/01/21  Troponin T <0.01 07/01/21  Bilirubin, Total 0.3 mg/dL 07/01/21  Bilirubin, Direct <0.2 07/01/21  Cholesterol, Fasting 144 mg/dL 07/01/21  Triglycerides, Fasting 58 mg/dL 07/01/21  HDL, Fasting 35.5 mg/dL 07/01/21  non-HDL Cholesterol 108 mg/dL 07/01/21  VLDL, Fasting 12 mg/dL 07/01/21  LDL, Fasting 97 mg/dL 07/01/21  Cholesterol/HDL 4.1 07/01/21  Amphetamine Screen, Urine Not Detected 07/01/21  Barbiturates Screen, Urine Not Detected 07/01/21  Benzodiazepine Screen, Urine Not Detected 07/01/21  Cannabinoids Screen, Urine Not Detected 07/01/21  Cocaine Screen, Urine Not Detected 07/01/21  Opiate Screen, Urine Not Detected 07/01/21  Ferritin 29.3 ng/mL 07/01/21  T4 (Thyroxine), Free 1.63 ng/dL 07/01/21  Hemoglobin A1c (NGSP) 5.4 % 07/01/21  Hemoglobin A1c (IFCC) 35 mmol/mol 07/01/21  A1c-derived eAG 108 mg/dL 07/01/21