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° CRR- 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:

12/7/10 14/7/10 19/7/10

Hb 13.3 14.6 14.3

TLC 12,400 11,100 10,700

DC N-86,L-10,M-2,E-2

N-79,L-18,M-2,E-1

Platelets 1,82,000 1,57,000

Blood Film Normocytic/Normoc hromic

Malaria parasite Negative

BIOCHEMISTRY:

12/07/10 14/07/10 19/07/10

Na/K 123/4.5 116/3.7 134/3.8

B.Urea/S.creatinine

82/1.1 29.8/1.1 37/0.7

Bilirubin(T/C) 0.43 0.6

AST/ALT 11.7

ALP 86

Total Protein/Alb 8/4.6

Ca/P 8.2/2.7

COAGULOGRAM

14/07/10

PT 15 Sec

PTI 86%

aPTT 24 Sec

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

•50y old male VK presented with h/o fever, headache for 5days,seizures and altered sensorium for 1 day•For the above mentioned complaints patient was admitted outside and treated (details NA)

12/7/10 •Patient was brought to EMOPD ,PGI, on examination GCS-12,neck rigidity present. so possibility of bacterial meningitis /? Viral meningoencephalitis was kept

CONT….• Patient was started

empirically on inj Ceftriaxone• Investigations showed CT

head-normal study, CSF analysis-no WBC, low sugar and high protein, gram stain negative

• possibility of viral meningoencephalitis kept;

• Patient was started on inj.ACYCLOVIR and was planned to get MRI brain which showed normal study.

CONT….

20/7/10• With initiation of therapy there was improvement in

sensorium but fever persisted• On 20th JULY 2010 he developed sudden respiratory

distress while taking feeds• Patient was intubated and was put on IPPR on 20/7/10;• Patient had sudden cardiac arrest on 20/7/10,CPR done

as per protocol but couldn”t be revived.

12-Jul 13-Jul 14-Jul 15-Jul 16-Jul 17-Jul 18-Jul 19-Jul 20-Jul0

2

4

6

8

10

12

14

GCS

Series1

12-Jul 13-Jul 14-Jul 15-Jul 16-Jul 17-Jul 18-Jul 19-Jul 20-Jul35.5

36

36.5

37

37.5

38

38.5

39

39.5

40

FEVER

fever

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

oPOSSIBILITIES

Febrile encephalopathy with no Focal deficit and fulminant course

A. Primary CNS involvement- Meningoencephalitis

1. Pyogenic 2. Viral 3.Amebic meningoencephalitisB. 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

o 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:

Bhalla A et al. J emergencies,trauma and shock 2010

Primary CNS infection

70%

Meningitis 33%

Meningoencephalitis

29.9%

Sepsis associated encephalopathy(SAE)

12.7%

Non infectious causes ADEM,CVT,NMS

26.2%

Unknown aetiology

11%

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

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