Abstract | November 18, 2023
A Masquerade of Pontine infarction
Learning Objectives
- Our learning objectives include primarily the gap we noticed in multiple domains of this patient’s care, the first being a wide array of confounding factors such as hyponatremia, general confusion, and weakness from an active infection; the nature of brainstem infarctions, which are deceptive in presentation. In this case, additional emphasis on the multidisciplinary approach of the ancillary team, such as physical therapy, nursing, and case management, which help in the identification of risks to safe patient discharge besides the most crucial communication gap, that being between the provider and the patient.
A 70-year-old male is discussed in this case, emphasizing the nuance and masquerading nature of brainstem strokes. This patient presents to us with very nonspecific complaints of dizziness, lethargy, cough, and shortness of breath, and on physical exam with no localizing clinical signs initially, and initial imaging and labs showing a radiologic pulmonary opacity and chemistries with a confounding factor of hyponatremia. Initial diagnosis and differentials included community-acquired pneumonia, atypical pneumonia, and hyponatremia. He was treated for concomitant pneumonia, and low sodium recovered on holding the patient’s hydrochlorothiazide, and with an overall improvement in the clinical picture, he was discharged.
He was evaluated with orthostatic vitals, which were negative; the physical therapist mentioned the patient was unsteady but able to walk—case management identified no needs prior to discharge.
He then presents to the ED the same evening, post-discharge, with worsening of prior symptoms, the primary complaint being lethargy, and with a higher clinical suspicion, head imaging (MRI) revealing a subacute infarction of the upper pons; this case highlights the nonspecific nature in which these patients may present.
References and Resources
- Malla, G., & Jillella, D. V. (2023). Pontine Infarction. In StatPearls. StatPearls Publishing.
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- Emes, M., Smith, S., Ward, S., & Smith, A. (2018). Improving the patient discharge process: implementing actions derived from a soft systems methodology study. Health systems (Basingstoke, England), 8(2), 117–133. https://doi.org/10.1080/20476965.2018.1524405
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