Tropic infectionCase Discussion

High Level Protein of CSF &

Dyslipidemia
in patient with Multiple Sclerosis

Presenter: Gilang Kusdinar

Moderator: Dr.Maimun Z.A., MKes, Sp.PK
1

Summary of Database
Mrs.

W/ 44 years old/ Hospitalized: 17-12-2014/ MR 10963445

Chief
The

complaint: Tetraparesis (weakness on 4 extremities)

patient suddenly felt weakness on legs 4 days before

admission (worsening than before) and 2 days before

admission, her arms and legs had weakness and numb.
She
No

also felt neck pain but didnt radiated.

complaint on her urination and passed stool.

She

felt decrease of appetite and body weight since 1 month

ago (8 kg).

 Past

medical illness:

Parese in her left extremity (4 months

ago) hospitalized 11 days without

clinical improved.
HT & Diabetes denied
History

of treatment:

Drug (from general practitioner)

months
Acupuncture

4
3

Physical Examination
General Appearance: moderately ill
GCS 456
BW:42 kg/ H: 156 cm
Vital
BP 90/60
Pulse: 110 x/ RR: 24 x/
Tax 36,6
0
Sign
m
mnt
C
Head
Conjunctiva anemis (-)
Sklera icteric (-)
Neck
Lymphadenopati (-), JVP R+0 cmH2O, pain (+)
Thorax
Cor
Ictus invisible, palpable in MCL (S) V
LHM ~ ictus
RHM ~ Sternal line D
S1-S2 single, reguler
Pulmo

Simetric, Stem Fremitus D = S

Auskultasi : Ronchi (-), Wheezing (-)
Soefl, BS (+) N, liver span 8 cm, lien unpalpable

Abdome
n
Extremit Warm acral, anemis (-), edema (-)

M 4 4

Laboratory Results
CBC

17-12-2014

23-12-2014

Hb

12,7

11,9

Eritrocyte

4,63

4,40

Hct

37,90

36,10

40 47

MCV

81,90

82,00

fL

80 - 93

MCH

27,40

27,00

pg

27 - 31

RDW

15,30

14,1

11.5 - 14.5

WBC

7470

19.880

/L

4300 - 10300

PLT

534.000

524.000

/L

142.000424.000

ESR
Diff count
(Eo/Ba/St/Se
g/ Ly/Mo)

Reference
g/dl

11,4 15,1

106/l 4,0 5,5

68
6/-/-/47/38/9

1/-/-/80/13/6

0-4 / 0-1/ 35/51-67/ 2533/ 2-5

Laboratory Results
17-12
RBS

20-12

21-12

81
96

65

60 100 mg/dL

116

< 130 mg/dl

11,40

19,00

16,648,5 mg/dl

0,55

0,54

<1,2 mg/dl

4,9

3,1

2,4 5,7 mg/dL

BG 2h pp
12,9

Creatinin 0,58

Reference
< 200 mg/dl

FBG
Ureum

22-12

Uric acid
SGOT

18

13

16

16

0 40 mU/dl

SGPT

29

17

18

18

0 41 mU/dl

Total
Chol.

184

235

< 200 mg/dL

TG

130

131

< 150 mg/dL

HDL-Chol

35

36

< 36 mg/dL

LDL-Chol

114

181

< 100 mg/dL

3,79

3,5 5,5 g/dL

Albumin

3,20

Electrolyte Results

Na

17-12-14 20-1214
138
134

22-1214
133

3,98

3,77

4,23

Cl

109

115

112

Reference
136-145
mmol/ L
3,5-5,0
mmol/ L
98-106
mmol/L
7

Hemostasis Result
20/12/14

22/12/14

PPT (sec)

11,1

13,40

Control (sec)

11.4

12.0

INR

0.96

1.15

29.20

35.30

24.3

25.3

PPT and APTT

within normal
limit

PPT and APTT

within normal
limit

APTT
Control (sec)
Conclusion

23/12/14
Clarity &
colour

Reference

pH

6,0

4,5-8,0

SG

1,025

1,0051,030

Glucose

Negative

(negative
)

Protein

Negative

(negative
)

Keton

Bilirubin

Urobilinogen

Urinalysis

Clear Yellowish

Trace

(negative
)

Negative

(negative
)

Negative

(negative
)

Microscopi
c
40x
Erythrocyt
e
Eumorphic
Dysmorphi
c

Ref.

7,2
-

3 HPF

Leucocyte

146,8

5 HPF

Crystal

LIQUOR CEREBROSPINAL
23/12/14
23/12/14
ANALYSIS
Macroscopic
Colour
Clot
Appearance
Microscopic
Erytrocyte
count
Leucocyte count
PMN
MN
Chemistry
Protein Total
Glucose
LDH
Special Test
Nonne
Pandy

Clear
Negative
Clear

Clear
Negative
Clear

300 /L
10 /L
0%
100%

400 /L
10 /L
0%
100 %

1091,6 g/dL
70
mg/dL
37
U/L

1086,0 g/dL
68
mg/dL
45
U/L

Positive
Positive

Positive
Positive

10

Cervical MRI (24-12-2014):

Intramedullar multiple lesion at level
vertebrae cervical C1-C2, C3-C4 and C5-C6,
susp. multiple sclerosis
HNP bulging type at level V C3-C4 and C4-C5
Discus and corpus degeneration of C2-T1
Spondylosis cervicalis and straight cervicalis

Chest X-Ray (18-12-2014):

Infiltrate and cavity in lobus superior (D)
Conclusion: susp. spesific process (TB
pulmonal) DD pneumonia
EKG (18-12-2014): Synus rythm, HR 98x/m

Data Interpretation
Laboratory results showed leukocytosis,
thrombocytosis, elevated total cholesterol,
lower HDL-cholesterol, elevated LDLcholesterol, elevated total protein and positive
nonne-pandy in LCS analysis, ketonuria,
nitrituria and leukocyturia.
From history taking, physical examination,
laboratory results and other examinations
indicated Multiple Sclerosis DD TB cervicalis;
with SIRS susp sepsis, and dyslipidemia.
Suggestion: Protein electrophoresis of
CSF,urine culture, FAB, sputum culture and 12

Discussion
1

Multiple Sclerosis
Multiple

sclerosis (MS) is a
neuroinflammatory and
neurodegenerative disease that results in
damage to myelin sheaths and axons in
the central nervous system and which
preferentially affects young adults.
This disease is characterized with
multiple neurological disorders
symptoms including vision, sensory, body
weakness, difficulties in walking and
Serum lipid
profiles
are associateddisorders
with disability and
MRI outcomes
abdominal
and
bladder
due
to in

multiple sclerosis

 MS

can be clinically divided into three

different major forms: relapsing
remitting (RRMS), secondary progressive
(SPMS) and primary progressive (PPMS),
respectively.
In addition, the clinically isolated
syndrome (CIS) has been described in
which a single episode of the symptoms
of RRMS patients may be a first
indication of MS.

Current diagnosis relies on clinical

examination supported by laboratory
investigations including Magnetic Resonance
Imaging (MRI) to visualise lesions, and CSF
biochemistry measurements that include
assessment of the oligoclonal band(s) of IgG
and barrier index.
CSF protein electrophoresis is for the detection
of oligoclonal bands representing
inflammation within the CNS.
The bands are located in the gamma region of
Multiple Sclerosis: Identification And Clinical Evaluation Of
the protein electrophoresis,
indicating
Novel CSF Biomarkers, Jan Ottervald
Et Al, Sweden. Journal Of

The CSF/serum albumin index is calculated

after determining the concentration of CSF
albumin in mg/dL and the serum concentration
in g/dL. The formula used is as follows:

An index value less than 9 represents an intact

blood brain barrier. The index increases relative
to the amount of damage to the barrier.
Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,
5th ed, 2008

Theory
Inflammatory,
demyelinating and
neurodegenerative
disease affect young
adult.
Disorders of vision,
sensory, body
weakness, difficulties in
walking and abdominal
and bladder
dysfunction.
Protein (CSF) findings
(elevated IgG index or 2
Suggestion:
or more oligoclonal
Protein
bands)
18
electrophoresis
of
MRI: 2 of 4 lesions
in

Patient
Female, 44 y.o
Tetraparesis
Patient cant walking
Numbness in 4
extremities
Neck pain
Thrombocytosis
MRI: Intramedullar
multiple lesion at level
V. Cervival
CSF: MN 100%, high
level of protein and
positive nonne-pandy.

Susp. Multiple
sclerosis DD TB

SIRS susp. sepsis in this patient ?

HR 110 x/min
RR 24
Day
VI: Leukocytosis (WBC
Day24
RR
VI: Leukocytosis (WBC

Suggestion:
Urine culture, Procalcitonin

Dyslipidemia in this
patient
MS

is an inflammatory disease in which

the myelin sheaths and axons are
destroyed.
Cholesterol is an important component
of intact myelin.
Lipids, especially lipoproteins, are
involved in the regulation of neural
functions in the CNS through local
mechanisms that are linked to systemic
lipid metabolism.

 High-density

lipoproteins (HDL) and lowdensity lipoproteins (LDL) play a key role

in the transport of cholesterol and lipids in
human plasma.
Under normal physiological conditions,
high concentrations of HDL and LDL are
present in CNS as a result of transport
across the blood-brain barrier.
MS patients were found to have a higher
occurrence of hypercholesterolemia and
paraoxonase-1, the anti-oxidant enzyme
associated with HDL, was decreased

In this patient
Female, 44 y.o
Low BMI
(Underweight)
Tetraparesis
Numbness in 4
extremities
Elevated total
cholesterol
Elevated LDLcholesterol
Disorder
Low HDL-cholesterol
regulation

of neural functions
in the CNS (lipid

MRI:
Intramedullar
multiple lesion at
level V. Cervival
indicated MS
CSF: MN 100%,
high level of
protein and
positive nonnepandy.

Increased
disability

Conclusion
It

has been discussed a case of 44 y.o female

with Multiple Sclerosis DD TB cervicalis; with
SIRS susp sepsis, and dyslipidemia, based on
history taking, physical examination,
laboratory findings and other examinations.
Dyslipidemia (hypercholesterolemia, high
level LDL and decreased HDL) are associated
with increased disability progression in MS.
Suggestion: protein electrophoresis of
CSF,urine culture, sputum culture, FAB and
procalcitonin.

Thank
You

SIRS, Sepsis and Septic shock associated with MODS

based on ACCP/SCCM Consensus Conference (USA 1992)
Systemic
Inflammatory
Response Syndrome
(SIRS)

2 / > clinical signs below:

Temp > 38oC or < 36oC
Heart rate > 90x/m
Tachypneu (RR >20x/m ) or
hyperventilation (PaCO2 < 32 mmHg)
WBC > 12,000/l or < 4000/l or > 10%
immature neutrophil (bands)

Sepsis (SIRS +
Source of infection)

Two or more SIRS criteria with suspected

or present source of infection.

Severe Sepsis

Sepsis with organ dysfunction,

hypotension or hypoperfusion (not limited
to the lactic acidosis, oliguria, altered
mental status), SBP < 90 or SBP drop 40
mmHg of normal.

Septic Shock

Severe sepsis with hypotension despite

adequate fluid resuscitation and
26
hypoperfusion.

Multiple Organ

Evidence of 2 organs falling

 There

is complete agreement that isoelectric

focusing (IEF) on agarose gels followed by
immunoblotting should be the gold standard
for detecting the presence of oligoclonal bands.
Other methods such as polyacrylamide gel
combined with IEF and silver staining of
proteins might have proven useful in the past,
but they lack specificity for IgG and, hence, are
not supported by consensus.
A direct comparison of the accuracy of the 2
techniques is given in Table 1.

 Candidate

biomarkers that significant

increases in the CSF levels: alpha-1
antichymotrypsin (A1AC), alpha-1
macroglobulin (A2MG) and fibulin 1.
Another biomarker that increases in the
CSF: protein contactin 1, fetuin A, vitamin
D binding protein and angiotensinogen
(ANGT).
Immunoassay
Measurement

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Strasinger SK &
Lorenzo M,
Urinalysis and
Body Fluids, 5th
ed, 2008

Strasinger SK &
Lorenzo M,
Urinalysis and
Body Fluids, 5th
ed, 2008

ESR

Pisetsky DS. Laboratory testing in the rheumatic diseases. In: Goldman L, Schafer AI,
eds.Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 265.

Multiple Sclerosis: Identification And Clinical Evaluation Of

Novel CSF Biomarkers, Jan Ottervald Et Al, Sweden. Journal Of

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Strasinger SK &
Lorenzo M,
Urinalysis and
Body Fluids, 5th
ed, 2008

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

Strasinger SK & Lorenzo M, Urinalysis and Body Fluids,

5th ed, 2008

Type IV cell-mediated disease

(syndrome, autoantigen and consequence)