Initial investigations:

CT scan

Stable periventricular white matter changes

Electroencephalogram

A moderate nonspecific generalized cerebral dysfunction. There were no epileptiform discharges or seizures recorded.

MRI brain

Increased demyelinating plaques since prior scan in 2015

MRI cervical spine

Numerous new demyelinating plaques throughout the cervical spine

MRI upper extremities

There is bilateral symmetric muscle edema without fatty infiltration/atrophy.

Upper limb arterial doppler

Normal left arm pressures and waveforms.

Total Lymphocyte

8400/mcl

ESR

12

CRP

6 mg/l

Urine toxicology

Cannabinoids positive

CSF analysis

Elevated protein and WBC count of 128 (53% PMNs, 42% lymphocytes). Lyme CSF, CSF VDRL were negative. CSF ACE levels within normal limits.

CSF Myelin basic protein

67.90 ng/mL

Lyme antibodies, HIV antibodies

Negative

Serum Vit B1, Vitamin B12, aldolase, serum copper, Serum immunoglobulins

Within normal limits

Immunological work-up

Negative

Blood, urine and sputum cultures

Negative

Cardiac work-up

ECHO (Day 4)

LVEF 50%. Moderate basal hypokinesis with preserved to hyper-contractile apical function. Normal RV systolic function, as shown in Figure 2(a).

ECHO (Day 14)

EF 55% - 60%, mildly hypokinetic segments in basal region (improved from previous study), Figure 2(b).

High sensitivity troponin

34 pg/ml à 37 pg/ml à 47 pg/ml