2. Case presentation:
A 30-year-old female patient referred from a suburban hospital of
western Nepal presented to the emergency department with chief complaint
of left-sided weakness which she noticed on waking up. She mentioned
that before waking up with weakness, she had experienced a gradual onset
debilitating frontal headache for the preceding 4 days but not relieved
with over-the-counter medications (Paracetamol and ibuprofen). The
headache was continuous, of throbbing nature but not associated with
fever, visual or sensory aura, photophobia, photophobia, nausea, or
vomiting. There was no diurnal or nocturnal variation in headache, not
associated with neck rigidity; however, it was associated with bilateral
ocular pain without double vision or vision loss. Her weakness was
progressive, gradually involving the right side of the body, and was
associated with an inability to speak and bladder/bowel incontinence.
There was no history of ear /nasal discharge, dental infection, cough,
sinus pain, surgery, or trauma. Further elaboration of history revealed
that she had been diagnosed with UC 18 months back and was on
immunosuppression under prednisolone and azathioprine. She had no
abdominal complaints including diarrhea recently. She had no other
comorbidities and was doing fine until this event. She is a non-smoker,
non-alcoholic. She was using a levonorgestrel implant as a birth control
method for the last 3 years. Her menstrual period was regular. She had a
positive family history of stroke in her mother in her 50s.
At presentation, her score on the National Institute of Health Score
Scale (NIHSS) was 7 and on the modified Rankin Scale (mRS) was 2. Her
vital signs were within normal limits. During the examination, she was
disoriented. Power was reduced in bilateral lower limbs
(4+/5) whereas it was normal in bilateral upper limbs
(5/5). The sensation was not assessable, neck rigidity was absent, and
reflexes were intact. The plantar response was flexor bilaterally.
Thorough cranial nerves and eye examination were unremarkable, and there
was no noticeable change in fundoscopy. She had no cognitive deficits.
Systemic examinations were within normal limits.
The hemogram, baseline coagulation profile were normal, however, D-dimer
(2.16 ug/ml), ESR (50 mm/hour), and CRP (25 mg/dl) were raised. The
coagulation parameters including factor level, homocysteine, and
antithrombin III levels could not be measured due to financial
constraints. Her cardiac enzymes, renal function test, liver function
test, lipid profile, and thyroid function tests were within normal
limits. The nasopharyngeal swab Polymerase Chain reaction (PCR) for the
SARS CoV-2 virus was negative. With the suspicion of CVT, plain and
contrast-enhanced Magnetic Resonance Imaging (MRI) of the brain with
Magnetic Resonance Venography (MRV) was sent. Infarction involving the
bilateral thalamus (Right > Left) was seen in ADC MAP
(figure 1) and 2.3 x 2.6 x 1.5 cm hematoma in the left parieto-occipital
region with thin extension to the adjacent area of the left temporal
lobe and perilesional edema with some mass effect (figure 2). Thrombosis
of the dural venous sinus thrombosis involving sigmoid dural venous
sinus (figure 3A), left transverse sinus (figure 3B) as well as the
straight sinus (figure 3C) was evident.
She was admitted to the Neurology ward with the diagnosis of bilateral
thalamic infarction with dural venous thrombosis due to a
hypercoagulable state secondary to UC. She was treated with subcutaneous
Heparin 40 U and monitored with APTT, intravenous Leveraticetem,
intravenous Dexamethasone, intravenous Mannitol, and intravenous
pantoprazole. Regular Azathioprine and steroids were continued for UC.
Once her condition stabilized, regular physiotherapy and acupuncture
therapy was done. Her hospital stay was uneventful. At discharge, the
patient was stable with an NIHSS score of 2 and a score mRS score of 1;
a motor power of 5/5 in the right upper/lower limbs and left upper limb
whereas it was 4/5 in the left lower limb. She was sent home on oral
Dabigatran and oral leveraticetem. All her regular medications were
continued at this time. A week following discharge, she developed
nausea, vomiting, and multiple episodes of diarrhea and was advised to
visit her gastroenterologist. Colonoscopic examination with biopsy
revealed severely active pancolitis. She underwent laparoscopic total
proctocolectomy with ileal pouch anal anastomosis with diverting
ileostomy. She was recovering well during follow-up.