Neurology Case Presentation Scott M. Shorten, MD PGY-3

Right-handed man CC: right facial droop, right arm and leg tingling and weakness

HPI recurrent drooping of the right face started 1.5 yrs ago without clear precipitant multiple times per day and while asleep, no warning, no trigger Average 30 minutes (5 min-2 hours), with complete recovery between Sometimes associated hand/arm numbness, no other consistent symptoms This episode concerning due to ‘stabbing’ mid-frontal headache with photo/phonophobia, left arm and leg weakness, and lasted over 2 hours. Onset while out in the heat gardening. ROS: fatigue, chest discomfort, neck pain

PMHx/SurgHx COPD Hyperlipidemia Depression Septic thrombophlebitis, R Cephalic vein Appendectomy Hemorrhoidectomy

Family History Mother: Bell’s Palsy, Thyroid disease Father: Meniere’s Disease Grandmother: Stroke

Soc Hx Married, lives locally Diesel mechanic Smokes 1ppd x 30 years No use of EtOH or Recreational Drugs

Medications Verapamil 60mg TID Carbamazepine 200mg BID Aspirin 325 qD Famotidine 10mg qD Trandolapril 2mg qD Multivitamin Simvastatin 40mg qHS Albuterol PRN Allergy: Minocycline

VS: 132/ p67 r18 GEN: alert, cooperative, pleasant, NAD. CV, Pulm, MSK examinations normal MS: oriented to person/place/time/situation Speech: slight labial dysarthria. Language normal. CN: NLF flattened on the right, decreased pinprick Right V1-3*

Motor: Tone and bulk normal, 5/5 throughout Sensory: decreased pinprick Right UE & LE Reflexes : Coordination: normal F-N-F and Heel-shin Gait: normal x4, no Romberg ~~ 3

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Workup (occurred over ~1 year) Imaging: – MRI of complete neuro-axis: normal – CTA head and neck: normal – Trans-esophageal Echocardiogram: normal – 4-vessel angiogram normal Prolonged and Video EEG negative for epileptic event, no slowing, no change on trial of Keppra PET: Left lower lobe infiltrate likely pneumonia, no neoplasm

Lumbar Punctures: RBCsWBCsProtGlu Presentation 9020 (88%L) days later (51%L) days later (77%L) month later months later months later (94%L) 7660

No growth of bacteria or fungus Cryptococcal Ab: negative Oligoclonal bands: negative IgG index 0.59 ACE: <4 Cytology: negative x4 Extensive workup with ID: unremarkable Autoimmune/paraneoplastic workup: normal DRVVT + on 3 months after presentation but normal on subsequent 6 months later: “possible transient due to viral infection” EBV studies: +Capsid IgG +Nuclear ag ab +Early ag ab; - Capsid IgM

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Mollaret’s Meningitis v. Pseudomigraine with Temporary Neurologic Symptoms and Lymphocytic Pleocytosis started empiric treatment with Acyclovir IV, then Valacyclovir 1000mg daily x 1 year Increased verapamil for continued possibility of vasospasm

Mollaret, P. Revue Neurologique Shalabi, M. Clinical Infectious Diseases Mollaret’s Meningitis Described in 1944 >3 episodes of fever and meningismus; weeks to years between Lasting 2-5 days, wide variation Spontaneous resolution ~50% with neurologic features Pierre Mollaret ( )

Most commonly due to HSV-2, often with muco- cutaneous lesions found elsewhere Diagnosis confirmed with CSF HSV PCR Valacyclovir prevented genital lesion recurrence in first year, but no change in meningitis frequency Canadian Medical Assn. Ginsberg L. Pract Neurol 2008;8: Aurelius E. Clinical Infectious Diseases.2012.

Pseudomigraine with Temporary Neurologic Symptoms and Lymphocytic Pleocytosis = Migrainous Syndrome with CSF Pleocytosis = Syndrome of Transient Headache and Neurologic Deficits with CSF Pleocytosis (HaNDL)

HaNDL First described in 1981 Self-limited, benign condition Transient neurological deficits - 15 minutes to 2 hours each, over weeks-months Moderate-Severe throbbing headache Lymphocyte predominant pleocytosis – Avg 199 cells (range ), most >90% Lymph; – avg protein 96, elevated in 96% – Glucose normal – Opening pressure elevated in ~50% Bartleson, JD. Neurology Gomez-Aranda, F. Brain. 1997

Usually in 30s-40s (range 7-52 yrs) 25-40% had preceding cough/rhinitis/fatigue/diarrhea No consistent gender predominance

Neuroimaging is usually normal – Leptomeningeal enhancement – Hypoperfusion on CT perfusion EEG generally shows slowing in the corresponding region Other Studies

HaNDL Etiology Inflammatory/Infectious? – Few reports; Echovirus, HHV-6. Migrainous? – SPECT imaging with decreased blood flow at sites corresponding to neurologic deficit – spreading cortical depression phenomenon Infectious, triggering cortical depression? Castels-van Daele, M. Lancet Emond, H. Cephalalgia Caminero, AB. Headache. 1997

Diagnosis / Tx Must first exclude more sinister causes CSF with >15 cells/mL of lymphocyte predominance Episodes of moderate-severe headache occurring with or shortly following symptoms Episodes recurring within 3 months Symptomatic treatment only, if needed The International Classification of Headache Disorders: Cephalalgia. 2004

Our Patient frequency of attacks 3-4 per day (from up to 20). Mostly affecting only his right face Usually associated with moderate headache Happy with improvement

Shalabi M, Whitley RJ. Recurrent benign lymphocytic meningitis. Clinical Infect Dis. 2006;43(9):1194. L Ginsberg, J Kidd. Chronic and Recurrent Meningitis. Pract Neurol 2008;8: Aurelius E, Franzen-Röhl E, Glimåker M. Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis. Clin Infect Dis. 2012;54(9):1304. Bartleson JD, Swanson JW, Whisnant JP. A migrainous syndrome with cerebrospinal fluid pleocytosis. Neurology. 1981;31(10):1257. Castels-van Daele M, Standaert L, Boel M, Smeets E, Colaert J, Desmyter J. Basilar migraine and viral meningitis. Lancet. 1981;1(8234):1366. Caminero AB, Pareja JA, Arpa J, Vivancos F, Palomo F, Coya J. Migrainous syndrome with CSF pleocytosis. SPECT findings. Headache. 1997;37(8):511. Gómez-Aranda F, Cañadillas F, Martí-MassóJF. Pseudomigraine with temporary neurological symptoms and lymphocytic pleocytosis. A report of 50 cases. Brain. 1997;120 ( Pt 7):1105.