Case Study: Stroke and Diaphragmatic Palsy leading to Pneumonia

Case Report

An 85-year-old male patient presented with complaints of weakness of the left half of the body for the past one month, cough with expectoration and fever for twenty days, and swelling of the left leg for seven days. He had a history of a past cerebrovascular event which had taken place about seven years ago, causing a weakness of the left arm and left leg, from which the patient had recovered completely following treatment. He also had a history of coronary artery disease four years ago for which he was put on antiplatelet therapy.

On examination, he had a left hemiparesis with grade 3/5 power (Medical Research Council grading) in the left upper and lower limbs. There was pitting edema and tenderness over the whole of the left lower limb. Coarse crepitations were present on the right side in the infraaxillary and infra scapular areas, with paradoxical abdominal movement predominantly on the right side.

On investigation, his hematological parameters exhibited leucocytosis (11,600/cu mm), anemia (hemoglobin 8.7 gm/dl) and biochemical parameters in the liver function tests (serum albumin-2.2 gm/dl, SGOT-100 IU, SGPT -76.1IU) and kidney function tests showed some derangements (serum urea 91.8 mg/dl, serum creatinine1.4 mg/dl). Arterial blood gas analysis showed low partial pressure of oxygen. A doppler study of the lower limb vasculature revealed deep vein thromboses involving the left common femoral vein, superficial femoral vein and popliteal vein.

A noncontrast CT scan of the brain showed an acute-on-chronic infarct in the right parietal region in the territory of right middle cerebral artery and lacunar infarct in the left thalamus(Figure 1).

Figure 1.

Axial non-contrast computerized tomography of the brain showing acute on chronic infarct in right parietal region in the territory of right middle cerebral artery

A chest radiograph showed a heterogeneous opacity in the right lower zone, and air bronchogram with an elevated right dome of the diaphragm (Figure 2).

Figure 2.

Chest X-ray PA view: abnormally elevated dome of right diaphragm with right lower zone consolidation

A previous chest radiograph, available from investigations done a month prior, was found to be normal. A right-sided diaphragmatic palsy was suspected, which was confirmed by ultrasonography, that showed grossly decreased diaphragmatic excursions on the right side.

Bronchoscopy was done, and Klebsiella pneumoniae grown on aerobic culture of the bronchoalveolar lavage fluid. An antibiogram showed extensive resistance of the organism against commonly used antibiotics while exhibiting that it was sensitive to meropenem.

The patient was diagnosed to have suffered a stroke which led to a left-sided hemiparesis, and a right sided diaphragmatic palsy, which led to pneumonia. He also had multiple deep venous thrombosis in the left lower limb.

The patient was admitted to the Intensive Care Unit (ICU), and provided mechanical ventilatory support, low molecular weight heparin, appropriate antibiotics, chest physiotherapy and supportive treatment. The patient was considered for diaphragm pacing but unfortunately before the therapeutic process could be set up, the patient succumbed to respiratory failure.

Discussion

In the present case there were two unususal presentations: first was the diaphragmatic palsy with brain lesion, without involvement of internal capsule, and the other was diaphragmatic involvement on the opposite side of hemiparesis.