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The patient presented with fever, altered consciousness, and seizures. While ischemic stroke was initially suspected, viral encephalitis or cerebral malaria should have also been considered given the association of fever. The management could have been improved by adding antiviral medication like acyclovir for possible viral encephalitis or anti-malarial drugs like artesunate for potential cerebral malaria. Dexamethasone and mannitol were also warranted to treat any cerebral edema from meningoencephalitis. Overall, a broader differential diagnosis and more comprehensive empirical antimicrobial therapy could have optimized treatment for this patient.
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- 1. Case Presentation Arsalan Masoud PGR,North Medical Ward Mayo Hospital, Lahore
- 2. Bio Data Patient’s NameNaseeba Bibi Age / Sex 60 year old Female Reg # 1742/15 Address Okara DOA 28-08-2015 MOA Emergency DOD 01-09-2015
- 3. Emergency Assessment andManagement Chief Complaints: ▪ Fever for 1 day ▪Altered state of consciousness for 1 day Relevant Examination: ▪BP: 170/80mmHg ▪BSL: ? ▪GCS 4/15 ▪Right Plantar Reflex Upgoing www.DrLizano.com
- 4. Investigations Advised: ▪Baselines ▪CT ScanBrain Plain ▪ECG ▪USG Abdomen Treatment Given: ▪Inj C-trox 1g IV x stat ▪Inj Zantac 50mg IV x stat ▪Inj Marzine 10mg IV x stat ▪PROVISIONAL DIAGNOSIS Ischemic CVA www.DrLizano.com
- 5. Presenting Complaints ▪ Fever3-4 Days ▪ Fits 3 Days ▪ ASOC 3 Days
- 6. History of PresentingIllness Patient was in usual state of health 3 days back when she developed fever which was sudden in onset, high grade, continuous, without any specific pattern or any diurnal variation and wasn’t relieved even on taking medications. Fever was associated with 2-3 episodes of tonic- clonic fits lasting for 1 minute each and relieved by Inj. Diazepam.This was accompanied with frothing from mouth.There was no h/o Up-rolling of eyes, no h/o urinary or fecal incontinence.The fits were followed by ASOC, which was sudden and progressive in nature. There was no h/o fits prior to this.
- 7. No h/o coughor sputum, No h/o of Sore throat, No h/o chest pain, No h/o Palpitations, No h/o SOB, No h/o Orthopnea or PND, No h/o Nausea orVomiting, No h/o Diarrhea or Constipation, No h/o Burning Micturition, No h/o of Oliguria, Polyuria or Hematuria. www.DrLizano.com
- 8. Past History: KnownAsthmatic 30 years with poor compliance to medication. Known Hypertensive 10 years with poor compliance to medication. No History of DM, IHD,T.B
- 9. Family History: Non Significant PersonalHistory: Non Smoker and Non Addict Drug History: Off and on medications for hypertension & Asthma
- 10. Physical Examination: A middleaged, obese, ill looking female patient lying unconscious in bed with vitals of B.P 150/90 mmHg Pulse 80/Min Temp 105º F R.R 24/Min O2 Sat 94 %
- 11. ▪ Pallor -ve ▪ Clubbing - ve ▪ Leukonychia - ve ▪ Jaundice - ve ▪ JVP Not Raised ▪ Cyanosis - ve ▪ Pedal Edema - ve ▪ Lymphadenopathy - ve www.DrLizano.com
- 12. Systemic Examination: Nervous System: GCSE1V1M2 4/15 Plantars B/L Mute SOMI - ve Pupils B/ L Normal, Reactive to light Tone B/L Normal of both upper and lower limbs Power and sensory system couldn’t be assessed patient being unconscious
- 13. Gastro-intestinal System: Soft, protuberantabdomen with no viscerae palpable on examination. Bowel sounds 3/min. Cardiovascular System: Apex beat in the 5th intercostal space just medial to the midclavicular line. S1 + S2 + 0 Respiratory System: Resonant, comparable percussion note B/L NVB + No added sounds on auscultation www.DrLizano.com
- 14. Investigations: CBC (29-08-2015) ▪WBC: 9.4Thousands/microL ▪Hb: 11.0 g/dL ▪HCT: 29.4 % ▪MCV: 91 fL ▪Plt Count: 187 Thousands/microL ▪Neutro: 67.1 % ▪Lympho: 27.4 % ▪Mono: 4.5 % www.DrLizano.com
- 15. 29-08-2015 LFTS ▪ S/Bilirubin 1.0mg/dL ▪ S/AST 71 U/L ▪ S/Alk. Phosphatase 242 U/L ▪ S/Total Proteins 6.5 g/dL ▪ S/Albumin 3.7 g/dL RFTs ▪ S/Creatinine 0.8 mg/dL ▪ Blood Urea 33 mg/dL www.DrLizano.com
- 16. 29-08-2015 Serum Electrolytes ▪ Sodium141 mmol/L ▪ Potassium 4.1 mmol/L ▪ S/Calcium 7.6 mg/dL ▪ S/PO4 3.7 mg/dL ▪ S/Choride 98.0 mg/dL ABGs ▪ pH 7.398 ▪ pCO2 43.6 mmHg ▪ pO2 83.4 mmHg ▪ HCO3 26.3 mol/L ▪ Base Excess -1.4 ▪ O2 Sat 88.9 % www.DrLizano.com
- 17. 30-08-2015 ▪ CSF Analysis ▪Volume: 3 ml ▪ Appearance: ClearWatery ▪ Xanthochromia: Negative ▪ Glucose: 83 mg/dL (BSL at that time 164 mg/dL) ▪ Protein: 68 mg/dL ▪ LDH: 40 U/L ▪ RBCs: 283/cmm ▪ WBCs: 63/cmm ▪ Neutrophils: 05% ▪ Lymphocytes: 95% ▪ No Atypical or Malignant cells were seen.Coagulation Studies PT 16 sec (control 14) aPTT 39 sec (control 35) www.DrLizano.com
- 18. ▪ CT ScanBrain Plain: ▪ Two CT scans were done. ▪ One of which was done on 28-08-2015 and the other done on 29-08- 2015. Study of both was unremarkable. ▪ USG Abdomen: ▪ Fatty liver with normal liver size, normal spleen and kidneys. ▪ Differential Diagnoses ▪ Ischemic CVA ▪ Meningoencephalitis www.DrLizano.com
- 19. Treatment Prescribed ▪ 28-08-2015 ▪Inj Omeprazole 40mg IV x OD ▪ Tab Motilium 1 x PO xTDS ▪ Tab Loprin 150mg 1 x PO x OD ▪ Tab Atorva 20 mg 1 x PO x H.S ▪ Syp Duphalac 2TSF xTDS ▪ Inf Ringer’s Lactate 1000mL IV x BD ▪ Tab Panadol 2 x PO x SOS ▪ 29-08-2015 ▪ Inj Diazepam IV x SOS ▪ Inj C-trox 1g x IV x BD ▪ Added to the previous regimen www.DrLizano.com
- 20. ▪ 30-08-2015 ▪ InjC-trox 2g IV x BD ▪ Inj Aclova 750mg IV xTDS ▪ Inf N/S 1000ml x IV x OD ▪ Inf R/L 1000ml x IV x OD ▪ Inj Artem 160mg IM x stat Then 80mg x IM x OD Inj Mannitol 100ml x IV xTDS Inj Diazepam x IV x SOS Tab Disprin 150mg 1 x PO x OD ▪ 31-08-2015 ▪ InjVancomycin 1g x IV x BD Added to the previous regimen www.DrLizano.com
- 21. Chronology of MorningDPNs ▪ 29/08/2015 ▪ Diagnosis: Ischemic CVA ▪ Pulse: 90/min ▪ Temp 106 ºF ▪ BP: 140/100 mmHg ▪ R/R: 18/min ▪ Chest: Clear ▪ GCS 4/15 ▪ Assessment: static ▪ Plan: CST ▪ 30-08-2015 ▪ Diagnosis: Ischemic CVA ▪ A/C: Fits ▪ Pt Critically ill ▪ GCS: 5/15 ▪ BP: 160/100 mmHg ▪ Pulse: 85/min ▪ Temp: 106ºF ▪ Plan: ECG, ABGs, Infusion Diazepam + Inj Epival + CST www.DrLizano.com
- 22. ▪ 31-08-2015 ▪ DiagnosisIschemic CVA/Meningo-encephalitis ▪ Pulse 98/min ▪ BP 150/90 mmHg ▪ Temp 104ºF ▪ Respiratory Rate 18/min ▪ Resp System NVB + B/L coarse crepts+ conducting sounds ▪ GCS 3/15 ▪ SOMI –ve ▪ B/L Plantars Mute ▪ Assessment Critical ▪ Plan: Baselines, MP Slide, Blood Cultures, LP results awaited, Lactodil Enema, HBsAg + Anti HCV www.DrLizano.com
- 23. WHAT WAS WRONGIN THE MANAGEMENT? Patient was having high grade fever before she had fits and went in an altered state of consciousness. Association of fever is important. www.DrLizano.com
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- 29. VIRAL ENCEPHALITIS ▪ Incase of suspicion of viral encephalitis Inj Acyclovir 10- 15mg/kg every 8 hours for 14- 21 days. ▪ Role of Mannitol? ▪ Inj Mannitol 1.5-2Gm/kg iv x TDS for two days then start tapering. ▪ Role of Dexamethasone? ▪ Inj Dexamethasone 2 c.c x IV x TDS ▪ It helps decrease Cerebral Edema in any case of Meningoencephalitis. ▪ It has no role in CVAs. www.DrLizano.com
- 30. CEREBRAL MALARIA ▪ Whento add an Anti Malarial in the Empirical Treatment? ▪ Hints pointing toward cerebral malaria ▪ In the absence of clear cut signs of meningism. ▪ Seizures both focal and generalized ▪ High grade Intermittent fever ▪ An abrupt lowering in Hb ▪ Multiple episodes of Hypoglycemia www.DrLizano.com
- 31. Anti Malarials inCerebral Malaria ▪ WHO recommends the use of injectables whenever cerebral malaria is suspected. (Plasmodium falciparum is attributed to Cerebral Malaria in most cases) ▪ WHO recommends Inj Artesunate 2.4 mg/kg IV/IM at 0, 12 hours, 24 hours,THEN qDay for 7 days or until patient can take oral drug ▪ Alternatively Inj Quinine dihydrochloride in a loading dose of 20mg/kg and then 10mg/kg each in three doses daily.This is diluted in 500ml of 5% D/W www.DrLizano.com
- 32. SUMMARY OF EMPIRICALTREATMENT FOR CEREBRAL INFECTIONS ▪ Inj Ceftriaxone 2g x IV x BD ▪ InjVancomycin 1g x IV x BD ▪ Inj Acyclovir 750mg x IV xTDS ▪ Inj Dexa 2 c.c IV xTDS ▪ Inj Mannitol 100-150 c.c IV xTDS(acc to edema on CT scan) ▪ Inj Artesunate 2.4mg/kg at 0, 12, 24 hrs and then OD until patient can take oral dosage or for 7 days. www.DrLizano.com
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