Slow-motion stroke
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Dr. Milap Patel
Slow-motion stroke
Suzanne Tobin, had been driven by her partner, James Rapp, from their Germantown home to the Hopkins ER in hopes that doctors there could determine what was causing her relentless deterioration. The first sign of a problem occurred in July 2013, when Tobin noticed a droop on the left side of her face, accompanied by slightly slurred speech. Now she could no longer walk unassisted, her speech was nearly unintelligible and her left hand was so weak she could no longer hold a book. Doctors in suburban Maryland had diagnosed a stroke -or possibly a series of strokes - but were unable to explain why Tobin kept getting worse by the week. An MRI showed evidence of lesions in the brain’s white matter, which controls overall function, suggestive of a prior stroke. Sometimes her blood pressure was deemed too high for PT. A new round of brain MRIs showed additional white matter lesions, a sign of further neurological injury. A spinal tap failed to find an infection. Multiple sclerosis, ALS, Lyme disease, and lymphoma had been ruled out. Tobin’s CD4 count, which measures a type of white blood cell that fights infection, was an alarmingly low 31; normal counts range from 500 to 1,500. Can you find out the cause?


Clue 1: It was not Lyme disease.

Clue 2: Tests ruled Amyotrophic lateral sclerosis (ALS) and Multiple sclerosis.

Clue 3: Atrial fibrillation was not the cause.

Clue 4: Doctors couldn’t find any malignant brain tumor or a blood clot.

Clue 5: Tobin did not have HIV or AIDS.
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Dr. M●●●p P●●●l
Dr. M●●●p P●●●l Neurology
Progressive Multifocal Leukoencephalopathy(PML) was the culprit. A second spinal tap revealed the answer.Tobin’s spinal fluid had high levels of the JC virus. This common virus, which affects most people in childhood, usually lies dormant and rarely causes problems - except in people with weakened immune systems.In immunocompromised people, the CD4 cells that normally keep the virus in check are vanquished and the JC virus replicates and invades the brain, attacking the central nervous system by destroying the myelin coating that protects nerve cells. Her low CD4 count has been classified as idiopathic CD4+ lymphocytopenia, or ICL. So far there is a little effective treatment for PML. Tobin takes a cocktail of drugs, including an antibiotic and an antifungal to ward off infections as well as mefloquine, an anti-malaria drug that has shown mixed effectiveness in treating PML. Although her CD4 count remains low, the level of JC virus in her spinal fluid has steadily diminished.... Read more
Mar 25, 2017Like