Table 1

- Historical and current information from the episode of care organized as a timeline.

Symptoms & History/TimelineClinical findingsDiagnostic assessmentTherapeutic intervention & follow-up outcomes
2 Months ago

  • - Bitemporal pressure-like headaches

  • - Nausea

  • - Non-projectile vomiting

  • - Blurry vision (right eye)

  • - Lacrimation

  • - Not applicable

  • - Not applicable

  • - Not applicable

2 Weeks ago
Presented at the ER complaining of severe headache and eye pain
Patient was seen in ophthalmology clinic and referred for neurological assessment due to bilateral disc papilloedema
Patient offered LP to R/O IIH and admission but refused and sign DAMA

  • -Not applicable (sign DAMA)

Ct brain negativeDiamox 250 mg BID
5 Days ago (day 1)

  • - Progressive symmetrical weakness in lower limbs (proximal muscles)

  • - Difficulty climbing stairs

  • - Difficulty getting up from a sitting position

  • - Not applicable

  • - Not applicable

  • - Not applicable

4 Days ago (day 2)

  • - Weakness progressed to involve distal muscles

  • - Not applicable

  • - Not applicable

  • - Not applicable

2 Days ago (day 4)

  • - Increased weakness necessitating assistance for walking

  • - Not applicable

  • - Not applicable

  • - Not applicable

1 Day ago (day 5)

  • - Severe weakness requiring assistance for walking

  • - Urinary incontinence

  • - Low-back pain

  • - Not applicable

  • - Not applicable

  • - Not applicable

Present -admission day

  • - Presented at ER again with a five-day history of weakness in her lower limbs.

  • - Persistent headache, nausea, vomiting, and blurry vision

  • - Patient admitted for work-up and management

  • - Fatigued, alert, and oriented.

  • - Bilateral papilledema.

  • - Upper limbs: normal motor coordination and sensory exam.

  • - Lower limbs:

  • - Hip extension, flexion, abduction, adduction: 2/5

  • - Knee and ankle dorsiflexion: 3/5

  • - Plantar flexion: 4/5.

  • - Absent knee reflex.

  • - +1 ankle reflex.

  • - +2 upper limb reflexes.

  • - Equivocal plantar responses.

  • - Normal muscle bulk and tone.

  • - Intact sensation.

  • - No scapular winging, percussion, grip myotonia, high arches, or hammer toes.

  • - Gait and station not assessed (patient cannot stand or walk)

  • - Highly positive Brucella abortus screening titer of 1:320.

  • - ELISA: IgM 0.49 (negative), IgG 2.72 (positive).

  • - Lumbar puncture: normal opening pressure, CSF with 300 WBC (97% lymphocytes), protein 487 mg/dL, glucose 3 mmol/L.

  • - Blood culture positive for Brucella melitensis, CSF culture negative.

  • - Normal biochemistry, CBC, creatine kinase, and hormonal profile.

  • - NCS: no evidence for large-fiber neuropathy.

  • - MRI brain: normal findings.

  • - Enhanced MRI lumbosacral plexus: abnormal diffuse enhancement of lumbar intradural nerve root in cauda equina

  • -LP done show high WBC Started initially on an empirical antimeningitis drug

  • - ID consulted and switch to anti-brucella medication

  • - Ceftriaxone 2 g IV BID for one month.

  • - Rifampicin 600 mg PO OD.

  • - Doxycycline 100 mg PO BID.

  • - Bactrim 160 mg IV TID for 3-6 months.

  • - three-week hospitalization with antibiotic management and physiotherapy.

  • - Improvement in headache and eye symptoms, persistent weakness - Discharged with referral to physiotherapy (two sessions per week) and home exercise program

60-Day follow-up

  • - Improvement in back and abdominal muscles

  • - Not applicable

  • - Not applicable

  • - Continued physiotherapy.

  • -Continued antibiotics.

90-Day follow-up

  • - Started walking short distances

  • - Not applicable

  • - Not applicable

  • - Continued physiotherapy.

  • -Continued antibiotics.

120-Day follow-up

  • - Dramatic positive change in physical abilities.

  • - Main remaining issue: difficulty climbing stairs

  • - Not applicable

  • - Not applicable

  • - Continued physiotherapy.

  • -Continued antibiotics.

ER - Emergency Room, LP - Lumbar Puncture, R/O - Rule out, DAMA - Discharge Against Medical Advice, IIH - Idiopathic Intracranial Hypertension, CSF - Cerebrospinal Fluid, CBC - Complete blood Count, NCS - Nerve Conduction Studies, MRI - Magnetic resonance imaging, ID - Infectious Diseases