From my short experience on Multiple Sclerosis.

Color enhanced, sagittal FLAIR MRI image of a person with long
 standing multiple sclerosis shows multiple hyperintense lesions
 (green) in the periventricular white matter which is characteristic of
 demyelinating lesions of MS.  Copyright SciencePhotoLibrary.

After being two years involved in basic science research, genetics and molecular testing during my training at Columbia University and SUNY Downstate (New York), learning how science is made and research is designed, ultimately implanted the idea of being a clinician capable to understand the pathophysiology and abnormalities behind a disease at a molecular level with adequate skills to propose, design and perform basic science research on patients.

Part of that idea came to life when I started working as a clinical trial coordinator and research assistant at the Neurology department of the Fundacion Santa Fe University Hospital at Bogota (Colombia). My short experience recruiting patients and subsequently following them at the multiple sclerosis clinic, under the guidance of one of my mentors, represented one of the best clinical experiences that affirmed my inclination to pursue a career as a neurologist. The constant interaction with participants in the study and the regular follow up visits, allowed me to establish good relationships with patients and caregivers.

Spending time in the clinic, also provided me with the opportunity to talk and explain the rationale of the project, several aspects of the disease, the ongoing research efforts and finally, our own preliminary results to patients and families. Three years after, I still consider this scenario as one of the most rewarding experiences a researcher could have and also, one of the main motivations to improve my training on the recognition of the clinical manifestations and the differential and radiological diagnosis.

 Attending to the training practicum session would be a highly valuable opportunity, especially in this early stage of my career when the consolidation of a good fund of knowledge on MS and related demyelinating conditions, the understanding of the mechanisms and relevance of the immune-modulating  and disease-modifying therapies will certainly impact both in my performance during residency and success as a future clinician-scientist. 

Stroke in Infants and Children

It's been a while since I post my last entry. Unfortunately, that's what happens to most of the blogs whom belong to non-writers or wannabe bloggers like me. The lack of consistency and updates make these kind of blogs less interesting, however, the discussion and the interest by intricated and challenging cases always will keep alive the academical discussion.
This is my first case posted on this blog, @EmilioEstrada07 on twitter raised his concern about the possible etiology, approach and workup of this clinical scenario, briefly depicted here. 


Papers to start:
1. Management of Stroke in Infants and Children

2. Closure or Medical Therapy for Cryptogenic Stroke with Patent Foramen Ovale 

For many centuries, healing by stroking a patient was
considered to be an effective treatment because
 it made use of the supposed phenomenon
of animal magnetism. This illustration depicts
Valentine Greatrakes curing a boy with this method.
Copyright: SCIENCEPHOTOLIBRARY

CASE
5 year old boy with no significant past medical history who was admitted for evaluation of sudden onset right sided weakness. Mother stated that he was trying to get to the bathroom but he was crawling instead walking. Mother felt that patient was joking and took him to the toilet. he then could not stand up and veered to the right and hit the wall. Mother asked him to grasp her fingers and there was clear weakness on the right, subsequently took him to local ER and realized that he was not able to talk.



Review of systems
On admission, there was no abnormal movements, no gaze deviation. No urine or bowel incontinence. Pt did not have seizures at any point in his life and there was no family history of seizures. No tongue color changes, no lip or oral ulcers, no fevers, no redness of his eyes. Never had anything similar in the past. Off note, he received regular immunization, MMR, Varicella (and two other vaccinations) 2 weeks prior to symptoms. No recent fevers. Family deny recent travel, rash or other bug bites. Mother stated he was a full term baby with no developmental problems.

Medical | Social | Surgical history
- uncomplicated pregnancy and delivery
- reached milestones on time
- older brother who is in good health
- lives with Mother, Father and brother

Physical Exam
Vital signs
BP 112/49 | Temp 97.7 °F (36.5 °C) | Resp 20 | Wt 18.144 kg (40 lb) | SpO2 98%
Gen: Awake/Alert, confortable
no lesions/ulcerations, no lymphadenopathy
RRR, nl s1/s2, low vibratory murmur heard best at left sternal border
Lungs, CTA Bilaterally
Neuro:
Mental Status and language function: Awake, responsive and following simple commands, right facial droop, Good eye contact, naming preserved, language intact, speech with slight dysarthria.
Cranial Nerves: He blinked on visual threat on both visual fields. Pupils were of equal (size: OD 3mm, OS 3mm) and exhibited a normal direct and consensual response to light. There was no RAPD. Ocular motility was full and there was no nystagmus evident. Right lower facial weakness. Hearing acuity was normal. Palatal movements were intact. There was no palatal myoclonus. Tongue in midline, able to move to both sides..
Motor Examination: Decreased muscle strength in the RUE, 3+/5 throughout, in RLE 4/5, able to move it by himself, overcame gravity. Normal muscle strength on the left throughout. Normal tone throughout.
Sensory: pin-prick test not performed, however noticed impaired light touch on right arm
Muscle Stretch reflexes: Muscle stretch reflexes were 2/4 throughout, Plantar responses were extensor on the right. No clonus.
Gait: Not able to stand up out of bed.

WorkUp.
       CBC:                         BMP
     \ 12.7 /                 143 | 107 | 18 /
6.8 -------216             -------------------82
      / 36.1 \                4.0 | 24 | 0.35 \

Diff: 43% Segs, 43% Lymphs, 9% Mono, 1% Baso, 4% Eosinophils
LFT's: Total protein 7.4 |Albumin 4.5|Tbili 0.2|AST 40|ALT 13|ALP 231|Ca 9.9
Coags: PT 13.1 PTT 34 INR 1.0
Lipids panel: normal | Troponin: Negative | CRP + ESR: normal
Lactic acid: 1.3 | Homocystein: 4.6 | D-Dimer: 260 | Factor VIII: 92% - WNL
Antithrombin III: 108% (Normal) | Lipoprotein A: 9.7 | APTT: 28.1 | INR: 1.1
Pending: Protein S: | Beta II Glycoprotein | Cardiolipin | Protein C |Prothrombin PCR | Factor V Leiden | Lupus Anticoagulant

EKG: Normal sinus rhythm
Echocardiogram: Levocardia. Atrial situs solitus. AV concordance.
Color Doppler flow mapping shows a tiny left-to-right flow signal across the fossa ovalis typical of a patent foramen ovale. No evidence for atrial thrombus.

MRI/MRA
Acute ischemic stroke of the left basal ganglia with no hemorrhagic conversion
MRA without evidence of malformations or aneurysms
Brain anatomy, intra, extra axial structures unremarkable.

Axial Diffusion-weighted images and AXL DWI correlation

Discussion

The patient was admitted for acute-onset of right-sided weakness, diagnosed with an acute ischemic stroke of the left basal ganglia in the territory of the small medial lenticulostriate arteries, with no previous history of blood dyscrasias, coagulopathies or known cardiac congenital abnormalities. Echocardiogram significant for patent foramen ovale with insignificant shunt from the left to the right per cardiology.  The possibility of a paradoxical embolism caused secondarily to a PFO, subsquently causing a DVT is unlikely on presentation but was ruled out with a saline contrast echo. Upper and lower extremities dopplers.The hypercoagulable panel still pending. The fact that patient had active immunization with varicella vaccine is still active part of the discussion.