Case Presentation

Arsalan MasoudPGR, North Medical WardMayo Hospital, Lahore

Bio Data

Patient’s Name Naseeba BibiAge / Sex 60 year old FemaleReg # 1742/15Address OkaraDOA 28-08-2015MOA EmergencyDOD 01-09-2015

Emergency Assessment and Management

Chief Complaints: ▪ Fever for 1 day▪Altered state of consciousness for 1 dayRelevant Examination:▪BP: 170/80mmHg▪BSL: ?▪GCS 4/15▪Right Plantar Reflex Upgoing

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Investigations Advised:▪Baselines▪CT Scan Brain Plain▪ECG▪USG AbdomenTreatment Given:▪Inj C-trox 1g IV x stat▪Inj Zantac 50mg IV x stat▪Inj Marzine 10mg IV x stat▪PROVISIONAL DIAGNOSIS Ischemic CVA

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Presenting Complaints

▪ Fever 3-4 Days▪ Fits 3 Days▪ ASOC 3 Days

History of Presenting Illness

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.

No h/o cough or 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 or Vomiting, No h/o Diarrhea or Constipation, No h/o Burning Micturition, No h/o of Oliguria, Polyuria or Hematuria.

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Past History: Known Asthmatic 30 years with poor compliance

to medication.Known Hypertensive 10 years with poor compliance

to medication.No History of DM, IHD, T.B

Family History: Non Significant

Personal History: Non Smoker and Non AddictDrug History: Off and on medications for

hypertension & Asthma

Physical Examination:

A middle aged, obese, ill looking female patient lying unconscious in bed with vitals of

B.P 150/90 mmHgPulse 80/MinTemp 105º FR.R 24/MinO2 Sat 94 %

▪ Pallor - ve▪ Clubbing - ve▪ Leukonychia - ve▪ Jaundice - ve▪ JVP Not Raised▪ Cyanosis - ve▪ Pedal Edema - ve▪ Lymphadenopathy - ve

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Systemic Examination:

Nervous System:GCS E1V1M2 4/15Plantars B/L MuteSOMI - vePupils B/ L Normal, Reactive to lightTone B/L Normal of both upper and lower limbsPower and sensory system couldn’t be assessed patient

being unconscious

Gastro-intestinal System:Soft, protuberant abdomen 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/LNVB + No added sounds on auscultation

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Investigations:

CBC (29-08-2015)▪WBC: 9.4 Thousands/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 %

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29-08-2015

LFTS

▪ S/Bilirubin 1.0 mg/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

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29-08-2015

Serum Electrolytes

▪ Sodium 141 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 %

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30-08-2015

▪ CSF Analysis▪ Volume: 3 ml▪ Appearance: Clear Watery▪ 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 StudiesPT 16 sec (control 14)aPTT 39 sec (control 35)

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▪ CT Scan Brain 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

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Treatment Prescribed

▪ 28-08-2015▪ Inj Omeprazole 40mg IV x

OD▪ Tab Motilium 1 x PO x TDS▪ Tab Loprin 150mg 1 x PO

x OD▪ Tab Atorva 20 mg 1 x PO

x H.S▪ Syp Duphalac 2 TSF x TDS▪ 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

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▪ 30-08-2015▪ Inj C-trox 2g IV x BD▪ Inj Aclova 750mg IV x TDS▪ 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 ODInj Mannitol 100ml x IV x TDSInj Diazepam x IV x SOSTab Disprin 150mg 1 x PO x

OD

▪ 31-08-2015▪ Inj Vancomycin 1g x IV x

BDAdded to the previous

regimen

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Chronology of Morning DPNs

▪ 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

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▪ 31-08-2015▪ Diagnosis Ischemic

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

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WHAT WAS WRONG IN 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.

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VIRAL ENCEPHALITIS

▪ In case 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.

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CEREBRAL MALARIA

▪ When to 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

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Anti Malarials in Cerebral 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

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SUMMARY OF EMPIRICAL TREATMENT FOR CEREBRAL INFECTIONS

▪ Inj Ceftriaxone 2g x IV x BD▪ Inj Vancomycin 1g x IV x BD▪ Inj Acyclovir 750mg x IV x TDS▪ Inj Dexa 2 c.c IV x TDS▪ Inj Mannitol 100-150 c.c IV x TDS(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.

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THANK YOU!

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