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Washington University Experience | MYELIN (IMMUNE-MEDIATED) | AHL | AHL | 3A0 Case 3 History
Case 3 History ---- The patient was a 57 year old man who had no significant past medical history. He presented to the ER with decreased responsiveness and new onset of seizures for one day. He became disoriented and fumbled getting into his car; at that point he was unable to talk and then he began to have a seizure. The patient was brought by ambulance to an outside hospital where he was described having left-sided focal seizures, a flaccid right-side and extensor posturing. The patient was intubated, started on Dilantin and transferred to our hospital. Upon arrival, he was febrile at 38.5oC with a heart rate of 102, blood pressure of 115/60 and a respiratory rate of 16. He could not follow commands. His pupils were equal in primary position with decreased response in the right visual field. He had normal gag and corneal reflexes. He moved his left side well with decreased movement of his right side; however, he would withdraw to pain in all four extremities. Deep tendon reflexes were 3+ throughout, toes were upgoing on the right and downgoing on the left. A CT scan revealed a hypodensity in the left anterior middle cerebral artery distribution with no bleeding. Initial laboratory evaluations showed a white count of 18.9 and a hemoglobin and hematocrit of 13.9 and 40.7, respectively, with 23,000 platelets. The patient was thought to have new left-sided seizures with a possible left hemispheric stroke. A lumbar puncture was performed which showed a protein of 127, glucose of 98, and total cells of 3100 with 1,000 nucleated cells, differentiated as 1% lymphocytes, 90% neutrophils, and 9% monocytes. The patient was started on Ceftriaxone and Ampicillin for possible meningitis. An angiogram, which was normal, was performed to evaluate possible vasculitis or vasospasm. The patient continued to show decreased responsiveness. An MRI was obtained which showed patchy diffuse cerebral edema, particularly in the left hemisphere, and involved the midbrain and pons with patchy involvement of the right hemisphere and left cerebellum with a risk of herniation. CSF PCR for herpes indicated a positive faint band with recommendations to repeat PCR; however, the final interpretation was no PCR confirmation of Herpes simplex encephalitis. By hospital day 5, the patient again began to show signs of increasing intracranial pressure and Mannitol was resumed. At this point, discussions were initiated with family about withdrawing support and the decision was made to extubate the patient who died shortly thereafter.
