Mucormycosis presenting as pure sensory stroke

60 year old male patient who is a known diabetic and Hypertensive - came with history 

1- headache since 15 days -unilateral , burning type with tingling and numbness, continuous type over left scalp and left supra orbital ridge ,frontal area which was sudden in onset ,severe intensity, unable to sleep since then ,not relieving with medications .

He also developed numbness of left --half of face ,ear ,mastoid and scalp region. 

Sudden onset of decreased vision in left eye ,with diplopia in left eye .

Decreased taste sensation over left side of oral cavity and left half of tongue .

 Unable to smell from left nostril .

Decreased hearing in left ear.

With severe headache and paresthesias he went to a local doctor ,Where routine investigations showed high sugars .CT brain showed - Infarcts in right capsuloganglionic region .

He was given antiplatelets ,and other treatment .

Suddenly today mrng at 3 am , patient woke up with severe headache and paresthesias over scalp ,that followed by numbness of left half of body .

Unable to feel clothes over the body ,unable to perceive pain sensation .

Weakness of left upper and lower limb ,unable to hold cup of tea with left hand and associated With involuntary movements of left upper limb during activity ., unable to roll on bed to left side ,slippage of objects from left hand , slippage of foot wear on left foot .

He is also Complaining of mild difficulty in swallowing for both solids and liquids ,no difficulty in chewing food .

Intermittently patient is unable to feel bowel and bladder sensations and having incontinence .

He is complaining of increase in frequency of micturition ,nocturia + .

No slurring of speech ,no drooling of saliva ,no deviation of mouth ,no difficulty in closing eyelids .

No history of fever ,trauma .

Patient is known DM and HTN since 8 years - compliant to medications .

He consumes toddy daily since 20 years .

Non smoker .

 On examination - 

 CNS - 

 Higher mental functions - 

 Patient is conscious ,coherent , coperative.

 Oriented to time place and person 

 Speech - normal 

 Memory - intact .

 

Gait - normal 

Cranial nerves - 

1st - unable to smell from left nostril 

2nd - pupils - normal size , reacting to light 

Decreased perception of light in left eye .

Visual acuity - Counting finger on left side - able to see partially ,with blurring of vision 

3rd ,4th ,6th - Extraocular movements normal 

5th nerve - sensory - decreased sensation over left half of face .

Motor - normal 

Corneal reflex and conjunctival reflex present but delayed .

7th nerve - motor - normal .sensory - decreased taste sensation over left half of ant 2/3 rd of tongue .

Frowning+ ,no deviation of mouth .

8th nerve - Rinnes test - Right side - bone conduction more than air conduction .

Left side - no air or bone conduction 

Weber's - lateralisation to right ear -

Sensorineural hearing loss on left ear 

9th ,10th - 

Palate movement - equal on both sides .

Uvula central in position 

Gag reflex + 

11th - shrugging of shoulder - normal power .

12th - no deviation of tongue ,no atrophy,no fasiculations.

Motor - normal .

 

 Motor system - 

 Tone - hypertonia on left UL and LL 

 Power - left UL - proximal -+4/5 

              Distal - -4/5 

              Hand grip -60 % 

Left LL - proximal and distal --4/5 

Reflexes - 

Right Left 

B- +3. +3 

T-+3. +2 

S- +3 + 2

K +1. +1 

A -. - 

P -Mute M 

Sensory system - 

Right half of body completely normal .

On left side of body there is decreased perception to touch ,pain , temp .

Absent joint position and vibration 

Cortical sensation - Steriognosis present .

Rombergs - ve 

Cerebellum - 

Finger nose incordination ,heel sheel incordination on left side -? Dysmetria 

Dysdiadikonesia + on left side .

No nystagmus 

No rebound phenomenon .

Diagnosis - ? Stuttering infarct 

Acute ischemic infarct - sensory more than motor - ? Right thalamic infarct / post limb of Internal capsule .