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Clinical  07 03-2011
 

Clinical 07 03-2011

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    Clinical  07 03-2011 Clinical 07 03-2011 Presentation Transcript

    • STUDENT CPC 07/03/11
    • PATIENT DETAILS
      Name: VK
      Age/Sex: 50y/male
      CR No:566023
      Adm.No:52869
      DOA:12/07/10
      DOD:20/07/10
      EMOPD
    • Presenting complaints
      Fever – 5 days
      Headache- 5 days
      Seizures- 1 day
      Altered sensorium - 1 day
    • History of presenting illness
      Fever- 5 days
      high grade, intermittent , not associated with chills and rigors, no diurnal variation, no aggravating and relieving factors.
      Headache-5 days
      sudden onset, holocranial, not associated with vomiting.
    • Cont…..
      Seizures- 1 day
      GTCS type, 4 episodes, each lasting for 15 sec, associated with frothing from mouth, no bladder/bowel incontinence.
      Altered sensorium - 1 day
    • Cont….
      • No h/o cranial nerve deficits
      • No h/o bleeding manifestations
      • No h/o focal neurological deficits
      • No h/o rash
      • No h/o trauma
      • No h/o ear discharge
      • No h/o bladder/bowel disturbances.
    • Past history:
      not known diabetic, hypertensive
      No other comorbid illnesses.
      Family history- non significant
      Personal history-
      Married, Mixed diet
      not known smoker/alcoholic
      no addictions
    • Physical examination
      • Alert,E3V4M5
      • Vitals:
      PR- 86/min, regular
      BP- 120/90 mm of Hg
      Temp- 37° C
      RR- 14/min
      • No pallor/clubbing/ icterus/cyanosis/pedal edema/lymphadenopathy/jvp(NR)
    • Systemic examination
      Per abdomen: Soft, non tender
      No hepatosplenomegaly
      FF(-),BS(+)
      Cardiovascular system: S1,s2 (+)
      No murmurs
      Respiratory system:
      bilateral air entry(+)
      normal vesicular breath sounds(+)
      no added sounds
    • CNS Examination
      • B/l pupils 2mm size, equally reacting to light
      Fundus examination-normal
      • Meningeal signs – Neck rigidity(+)
      • Extraocular movements normal, No nystagmus
      • No facial asymmetry
      • Motor system: Tone normal in all four limbs
      Power 5/5 in all four limbs
      DTR- B T S K A P
      Rt 1+ 1+ 1+ 1+ 1+ f
      Lt 1+ 1+ 1+ 1+ 1+ f
      • Sensory system- with in normal limits
      • Cerebellar system-with in normal limits
    • hemogram:
    • BIOCHEMISTRY:
    • COAGULOGRAM
    • csf analysis:
      TC- No WBC seen
      Protein-198mg,Sugar-28mg (CBS-106 mg)
      CSF glucose/ serum glucose- 0.26
      Gram stain- negative, C/S- Sterile
      Indian ink stain-negative
    • RADIOLOGY
      CECT brain- Normal study
      NCCT head-- Normal study
      CEMRI Brain – Normal study (films not available)
    • Course and management
    • CONT….
    • Cont….
    • DATABASE
      • 55y old male , farmer, married, non alcoholic, no previous co morbid illness
      • Presented with symptoms of fever, headache, seizures and altered sensorium.
      • Investigations revealed—
      • High total leucocyte count, hyponatremia
      • CSF analysis- No WBC, High protein, low sugar, Gram stain & culture- sterile ,Indian ink stain-negative
      CEMRI Brain- normal study
      CECT Brain- normal study
      • possibilities
      • Febrile encephalopathy with no Focal deficit and fulminant course
      A. Primary CNS involvement- Meningoencephalitis
      • 1. Pyogenic
      • 2. Viral
      • 3.Amebic meningoencephalitis
      B. Secondary CNS involvement
      • Septic encephalopathy
    • Acute bacterial meningitis
      FOR
      • h/o fever, headache
      • h/o Altered sensorium
      • Neck rigidity (+)
      • CSF showing high protein and low sugar
      AGAINST
      • h/o seizures
      • CSF showing no wbc, gram stain and culture - sterile
      • CECT brain- normal study
      • MRI brain- normal study
      • MOST LIKELY
    • In a prospective observational study conducted in our institute among 127 patients who presented to emergency services with fever(duration<2 wks) & altered mentation over 1 year
      Results:
      BhallaA et al. J emergencies,trauma and shock 2010
      • Seizures have been described in 15 to 30 percent of patients with bacterial meningitis and focal neurologic deficits in 10 to 35 percent of patients.
      Durand, et al. Acute bacterial meningitis in adults. N Engl J Med 1993; 328:21
      • An observational study found that bacterial meningitis was highly probable (≥99 percent certainty) when any one of the following parameters was present: a CSF glucose concentration below 34 mg/dL (1.9 mmol/L), a protein concentration above 220 mg/dL, a white blood cell count above 2000/microL, or a neutrophil count more than 1180/microL. CSF glucose concentrations less than 18 mg/dL (1.0 mmol/L) are strongly predictive of bacterial meningitis
       Spanos et al.. JAMA 1989; 262:2700.
    • Normal or marginally ↑CSF WBC -> 5 to 10 % and are associated with an adverse outcome
      New Engl J Med 2006;354:44-53
      • CSF bacterial cultures are positive in >80% of patients, and CSF Gram's stain demonstrates organisms in >60%.
      Harrison principles of internal medicine,17th edition
    • In a prospective study involving 301 adults with suspected meningitis confirmed that clinical features can be used to identify patients who are unlikely to have abnormal findings on cranial CT (41 percent of the patients in this study), 235 patients who underwent cranial CT, in only 5 patients (2 percent) was bacterial meningitis confirmed
      Hasbun R et. N Engl J Med2001;345:1727-33
    • VIRAL MENINGOENCEPHALITIS-CAUSES
    • Acute viral meningoencephalitis
      FOR
      • h/o headache, fever
      • h/o Altered sensorium
      • h/o seizures
      AGAINST
      • No focal neurological deficits
      • CSF –No WBC, low sugar
      • MRI-normal study
    • Cont…
      CSF shows low glucose in following viral causes of meningoencephalitis: mumps, LCMV, advanced HSV meningoencephalitis, Varicella zoster virus,
      Echo virus , Enterovirus
    • Primary amebic meningoencephalitis
      FOR
      • h/o fever, headache
      • h/o seizures
      • h/o neck rigidity
      • CSF showing negative g/s & culture
      AGAINST
      • No h/o swimming in fresh water lakes.
      • No h/o focal deficits
      • CSF glucose- < 40 mg
      • MRI brain- normal study
    • Sepsis associated encephalopathy
      FOR
      • h/o Fever, Altered sensorium
      • CT brain-normal study
      • MRI brain-normal study
      LESS LIKELY
      AGAINST
      • Neck rigidity(+)
      • CSF- low sugar
      • Liver function tests& renal function tests-normal
    • Final diagnosis
      ACUTE PYOGENIC MENINGITIS
    • Terminal event
      • Raised Intracranial pressure
      • Aspiration Pneumonitis
    • thank u