Opsoclonus Syndrome: A Case Study

CASE STUDY PROGRESS: The client has now received 3 cycles of combination chemotherapy for her breast cancer. Her last treatment with doxorubicin, cyclophosphamide, and 5-fluorouracil was approximately 12 days ago. She came to the emergency room with a 2-day history of fever, chills, and shortness of breath. On arrival, she is disoriented and agitated. Vital signs are 86/43, 119, 28, 39.8° C, SaO2 85% on room air. Laboratory data include WBC 1.2 thou/cmm, Hct 24.9%, Hgb 8.7 g/dl, platelets 125 thou/cmm. Differential WBC count shows 37% granulocytes, 60% lymphocytes, 3% monocytes. Chem 14 is within normal limits, with the exception of BUN 28 mg/dl, creatinine 1.6 mg/dl, and lactic acid 2.4 mg/dl. Chest x-ray demonstrates diffuse infiltrates in the left lower lung.

I was well versed with the patient’s medical history and current treatment, as I was the Long Call IM PGY – II Resident who supervised the medical intern when this patient was being downgraded from the ICU to the medical floor on 5/20/17 (and even suggested to the medical intern to add in her notes that the patient would benefit from statins, ACE inhibition and Spironolactone given CAD, CVA and HFrEF (LVEF < 35%.) The medical team subsequently started the patient on Atorvastatin 40 MG PO QHS, Lisinopril 10 MG PO QD and Spironolactone 12.5 MG PO QD.

Final diagnoses: (1) Epistaxis secondary to Coumadin, (2) recurrent cancer of vestibule of the mouth, (3) atrial fibrillation, (4) transfusion nonautologous plasma through peripheral vein.

Review of the medical record indicates that he had a MVA in 1977 with C4-5 injury that resulted in him been a Quadriplegic. Due to his bedbound and immobility status he has had multiple pressure ulcers over the years that have resulted in hospital admission and rehab stays. Other medical history include, HTN, hyperlipidemia, Sacral pressure ulcer, Right hip pressure ulcer, Constipation, depression. Bilateral arm contractures, bladder cancer, prostate cancer, urostomy and colostomy, aspiration pneumonia, neuropathy and MRSA.

A review of his medical record indicates that he has HIV and is being treated with antiretroviral medications. He also has HIV-associated Hodgkin's Lymphoma and history of fracture to back. He is currently being treated with chemotherapy. He has completed 8 chemotherapy treatments with 4 remaining treatment. He is schedule to start radiation therapy next week. He is followed by Dr. Rosen for oncology and Dr. Ramgopal for infectious disease.

“Relapses can have devastating consequences for people with mental disorders such as schizophrenia, bipolar disorder, depression, or an anxiety disorder. After every relapse, it may become increasingly difficult to regain control over the symptoms. For this reason, it is especially important for people with a mental disorder to do all that is possible to reduce the risk of a relapse”

DMTs reduce the relapse rate but some also reduce brain atrophy and slow disease progression. Medications such as one of the injectable INFs or glatiramer acetate are first line recommendations due to their long history of safety and efficacy. However, in the last ten years the options for treatment have grown substantially with the introduction of DMTs with better dosing schedules and administration routes. There are now three oral medications that all have different mechanisms of action: fingolimod, dimethyl fumarate and teriflunomide. They are all now used as first line treatments or to replace INFs or glatiramer acetate in patients who have developed neutralizing antibodies that have reduced the effects of those medications. Several second line treatments have been developed to treat patients who either did not respond to first line treatments or have progressive types of MS. They include an immunosuppressant chemotherapy agent (mitoxantrone) and two monoclonal antibody medications (alemtuzumab and natalizumab). These medications are available by infusion only and have much riskier side effects including the development of other auto-immune disorders and progressive multifocal leukoencephalopathy (which can be fatal). DMTs are approved for patients with relapsing forms of MS, but patients with non-remissive courses have fewer treatment options. For example,

DATA: Today’s group has been facilitated by Kirsten again, and includes relapse, what it is, and how each client can prevent it. Being that relapse is a process, it is an ongoing situation that can be interrupted, rather than a static event that is over and cannot be changed. It involves the individual reverting to old attitudes, beliefs, values, and risk behaviors. These are part of a progressive pattern, and will worsen until the process is interrupted or changed. Relapse is not a sign of failure, and, at times, may be part of the recovery process. There are times when individuals are more vulnerable to relapse, specifically, when they are too hungry, angry, lonely, or tired (HALT), and need to be aware of this vulnerability, and take

Also, if caught early enough, the less likely there will be residual brain damage and memory impairment. Treatment for WKS is immediate administration of thiamine. Thiamine doses differ from patient to patient depending on severity of the WKS. Oral thiamine supplements are not effective in severe cases because of the liver damage and disrupted thiamine metabolism. It usually is administered intramuscularly. Taking the thiamine may not completely reverse all damage, but can prevent the progression of the disease. Also, a few lifestyle changes should be made, including a complete diet and refraining from heavy

On 4 June 2018 at around 2pm, I visited Mr. Mueller at his home located on Fort Drum, NY. Mr. Mueller is awake, alert, and oriented to person and location. When evaluating his hearing, Mr. Mueller is able to repeat whispered words appropriately. Evaluation of breathing pattern while watching his nostrils reveals unlabored breathing with no nasal flaring. Lymph nodes post-auricular, submandibular, and supraclavicular are not swollen and Mr. Mueller does not report pain during palpation of lymph nodes. Assessment of eyes reveals bilateral quick reacting pupils to light. Extraocular movement test is normal; Mr. Mueller is able to follow the pen with his gaze. Lung sounds are clear bilateral, breathing pattern

The patient appeared to be alert, very engaging during the counseling session, and No evidence of SI/HI. The patient does his treatment plan goals in every counseling session and his coping mechanism.

However, the results of many clinical trials promulgate its inefficacy and unreliability, with high relapse rates and a dependence on therapist competence.13

4- Was the transplant given for recurrent PB or one time occurrence with other signs of failed Fontan.

noted. He will follow up in 3 months when further injections are needed. He is to

In present study, all patients had no recurrence after treatment during follow period. The previously reported mortality range is from 0% to 28%. Effect factor of mortality is depending on the site of infection, the time to diagnosis, the time to the start of appropriate treatment, co-existing central nervous system disease [27]. In present study, there was no surgery related complication and