A diabetic male with ams fever and hallucinations
Download
1 / 59

A Diabetic Male with AMS, Fever, and Hallucinations - PowerPoint PPT Presentation


  • 56 Views
  • Uploaded on

A Diabetic Male with AMS, Fever, and Hallucinations. Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' A Diabetic Male with AMS, Fever, and Hallucinations' - vanna-rodgers


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Edward P. Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL


Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL


Global objectives
Global Objectives

  • Maximize patient outcome

  • Utilize health care resources well

  • Optimize evidence-based medicine

  • Enhance ED practice


Sessions objectives
Sessions Objectives

  • Present case

  • Review key concepts

  • Consider relevant questions

  • Examine treatment options

  • Develop reasonable Rx strategies


Ems presentation

EMS Presentation…

51 year old 0028 CFD EMS call for AMS

Per family, high temp, flu-like symptoms

Fever and hallucinations

Hot, flushed, diaphoretic, O x 1

VS 140/P, HR 120, RR 30

Glucose 300

Hx DM, HTN

Recent viral illness


Ed presentation

ED Presentation…

August 2002, Illinois, 1:01 AM

ED Presentation non-verbal, moaning

Temp 102.2

Viral Sx, N/V/D for 2 days

Taking NSAIDs, refused PMD admit

Responds to verbal, moans “Help me.”


Ed history

ED History…

ED Presentation non-verbal, moaning

Temp 102.2

Viral Sx, N/V/D for 2 days

Taking NSAIDs, refused PMD admit

Responds to verbal, moans “Help me.”

No drugs or EtOH history

Hx psoriasis


Ed physical exam

ED Physical Exam…

Agitated, confused, combative, diaphoretic

Pupils 2-3 mm, non-reactive; airway OK

Neck supple, no thyromegaly

Cardiopulmonary: tachycardia, tachypnea

Abdomen non-tender

Neuro: CN grossly normal, no motor weakness, tremor, intermittent nystagmus on central gaze

Skin: old psoriasis, no new rash


Clinical questions

Clinical Questions

What are the differential diagnoses?

What are the etiologies?

What tests must be performed?

What therapies must be provided?

What consultations are required?

What outcome is likely?


Ed management

ED Management…

DDx: Viral Sx, AMS

R/o encephalitis, meningitis, sepsis

Need to R/o West Nile Virus (Illinois)

1:15 Haldol, ativan

1:25 RSI with etomidate, pavulon, sux

4:40 Ceftriaxone 2 gr IV

4:55 Acyclovir 1 gr IV over 1 hour


Ed diagnostics

ED Diagnostics…

WBC 11,900 Hb 16.1

Glu 313, Bicarb 25, chem ok

7.33 / 39 / 79 / 22 / 97%

CXR: no clear infiltrate

EKG: sinus tach

UA: no UTI

CT: no lesions

LP: Unable x 2


Consultations

Consultations…

Neuro consult: LP under fluoro, EEG

ID consult:

R/o septic shock, resp failure

R/o staph, given psoriasis

R/o pneumococcal pneumonia

R/o meningitis

R/o toxic or metabolic encephalopathy

Add vancomycin, obtain 2-D echo


Hospital course

Hospital Course…

LP by neurosurgery:

20 WBC, 20 RBC, glu 137, protein 32

ID: viral synd, R/o aseptic meningitis

Day 3: Possible sub-endocardial AMI

Day 3: Seizure, rx with fosphenytoin

Rocephin changed to cefipime, levaquin

Day 9: More responsive, temp to 102.6

Day 10: Maculopapular rash


Hospital course1

Hospital Course…

EEG: Non-specific diffuse slowing

ECHO: LV dysfunction

Blood cultures negative

Repeat CT: maxillary sinus fluid

PCR negative for herpes simplex virus

Tests for systemic vasculitides negative

Ab for myeloperoxidase

Ab for proteinase-3


Hospital course2

Hospital Course…

Legionella Ag in urine negative

Mycoplasm antibody titre negatvie

Chlamydia pneumoniae IgG, IgA positive

HIV Ab negative

Day 11: West Nile Arbovirus (CSF) +


Patient outcome

Patient Outcome…

PM & R Consult: Comprehensive rehab

Pt extubated, improved neurologically

Pt able to understand plan

Discharge on day 26:

nursing home/rehab care

able to speak, ambulate

beginning to meet needs

Seen in ED by same EM MD, doing well


Fever ams differential dx

Fever, AMS Differential Dx

Encephalitis

Meningitis

Meningoencephalitis

Encephalomyelitis

Sepsis


Viral encephalitis etiologies

Viral Encephalitis Etiologies

Arboviruses: mosquitoes, ticks

Herpes viruses:

Herpes simplex

Epstein-Barr

CMV

Varicella zoster

Measles virus


Encephalitis pathophysiology

Encephalitis Pathophysiology

Brain inflammation

Usually caused by a viral etiology

Focal, multi-focal, or diffuse

Cerebral edema, hemorrhage, neuronal death


Encephalitis pathophysiology1

Encephalitis Pathophysiology

Blood borne CNS infection

Diffuse encephalitis

Transmitted thru other tissue

Focal infection

DNA or RNA viruses


Arbovirus encephalitis

Arbovirus Encephalitis

Mosquitoes or ticks (vectors)

Vector-transmitted infection

Mosquitoes

10% encephalitis rate if infected

150 to 3000 cases per year

Ticks

Rocky Mountain spotted fever

Non-US Russian encephalitis


Herpes virus encephalitis

Herpes Virus Encephalitis

Able to lie dormant and reactivate

HSV causes 10-20% of all cases

2 per 1,000,000 persons per year

Usually HSV-1 from oral herpes

Children, both HSV-1 and –2

Only treatable cause of encephalitis


Varicella encephalitis

Varicella Encephalitis

Bad if related to chicken pox

Adults and children

In zoster, less severe unless immunocompromised

Both types are rare


Epstein barr encephalitis

Epstein-Barr Encephalitis

Related to mononucleosis

Fatigue, sore throat, HA, fever

1% encephalitis rate

Usually mild


Cmv encephalitis

CMV Encephalitis

5-10% complication rate

In HIV patients, 50% complicated

Significant mortality


Other encephalitis causes

Other Encephalitis Causes

Rabies

Severe, fatal

16 cases between 1980-91; 8 US

Measles, influenza

Adenoviruses

30% mortality rate if encephalitis

Symptoms of meningitis, coma

Parasites: raccoons, toxoplasmosis


What is adem

What is ADEM?

Acute disseminated encephalomyelitis

Non-infectious encephalitis

2-3 weeks after a viral illness

1/3 of encephalitis cases

Varicella, URIs are common causes

Autoimmune reaction, white matter

Myelin sheath damage, as in MS


Arbovirus encephalitis1

Arbovirus Encephalitis

Eastern equine

Western Equine

St Louis

California

Japanese B

West Nile


Arbovirus encephalitis sx

Arbovirus Encephalitis Sx

St Louis & West Nile common in US

Less than 1% cause CNS symptoms

Sx 2-14 days post-exposure

Fever, HA, N/V, lethargy

West Nile Virus:

Maculopapular rash, morbilliform rash

Loss of muscle tone and weakness


Arbovirus motor sx

Arbovirus Motor Sx

Motor disorders common

Severe general weakness

Ataxia, voluntary motor problems

Tremor, partial paralysis

Dysphagia, Broca’s aphasia

Hearing and visual symptoms


Encephalitis sx

Encephalitis Sx

Sudden onset

Meningismus

Stupor, coma

Seizures, partial paralysis

Confusion, psychosis

Speech, memory symptoms


Encephalitis diagnosis

Encephalitis Diagnosis

Find treatable etiologies

CT: no changes early

MRI: early HSV changes detectable

EEG: temporal lobe HSV changes

LP: elevated WBCs and protein

Labs:

Leukocytosis, LFTs, coags, chem, tox

Viral cultures


Encephalitis serum ab tests

Encephalitis Serum Ab Tests

Virus only at 2-4 days (too early)

Serum Ab titres

Low early levels

4-fold increase in convalescent tires

Obtained 3-5 weeks after sx onset

PCR: will replicate virus DNA

Quick results (hours)

Sensitivity equal to viral culture


Ruling out viral meningitis

Ruling Out Viral Meningitis

Self limited

Headache, photosensitivity

Stiff neck

Fever, N/V, fatigue also common

Confusion, psychosis not seen

Exclude mycoplasma, legionnella


Treating viral encephalitis

Treating Viral Encephalitis

Antibiotics for presumed meningitis

Acyclovir for presumed HSV Dx

Steroids?

Supportive therapies

Seizure Rx

Sedation

Airway control

Pain and fever meds


Viral encephalitis anti virals

Viral Encephalitis Anti-virals

Acyclovir for presumed HSV, HZ

Foscarnet (Foscavir)

When resistant to Acyclovir

If adverse reaction to Acyclovir

Foscarnet or gancyclovir in CMV

Ribavirin (Virazole)


Encephalitis pt outcome

Encephalitis Pt Outcome

25% relapse rate in HSV disease

? Due to relapse or new viral illness

Poorer outcome with:

Age < 1, > 55

Immunocompromise

Pre-existing neurological problem

Specific virus virulence

Coma does not = bad outcome


Encephalitis pt outcome1

Encephalitis Pt Outcome

Outcome related to mental status at the time anti-viral Rx initiated

Early use is warranted

Long-term sequelae can occur

Motor, speech, cognitive

Emotional, personality changes

Sensory problems (vision, hearing)


Encephalitis vaccines

Encephalitis Vaccines

Measles vaccine

Varicella vaccine

Rabies vaccine, immunoglobulin

Japanese encephalitis vaccine

Experimental West Nile Virus vaccine


West nile virus encephalitis

West Nile Virus Encephalitis

Mosquito-borne, expanding area

1/5 mild febrile illness

1/150 meningitis, encephalitis

Advanced age is greatest risk factor

Clues as to likely WNV infection:

Infected birds or cases identified

Late summer

Profound muscle weakness


West nile virus encephalitis1

West Nile Virus Encephalitis

IgM Ab testing via Elisa useful

Test of serum or CSF

False positives can occur

Other flaviviral infections (dengue)

Prior vaccination (yellow fever)

Rapid reporting is essential




U.S. counties reporting any WNV-infected

birdsin1999(N = 28 counties)


U.S. counties reporting any WNV-infected

birdsin2000(N = 136 counties)


U.S. counties reporting any WNV-infected

birdsin2001(N = 328 counties)


U.S. Counties Reporting WNV-Positive Dead Birds, 2002*

15,745 birds

1,888 counties

42 states & D.C.



Wnv encephalitis diagnosis

WNV Encephalitis Diagnosis

Leukocytosis, lymphocytopenia

Hyponatremia

CSF pleocytosis, lymphocytes

Elevated CSF protein

Normal CT

MR: enhanced leptomeninges or periventricular areas


Encephalitis mr findings
Encephalitis MR Findings

  • Inflamed portion of the temporal lobe, involving the uncus and adjacent parahippocampal gyrus, in brightest white on MR.


Wnv antibody diagnosis

WNV Antibody Diagnosis

ELISA detection of WNV IgM

95% CSF WNV IgM rate

IgM does note cross BBB

CSF IgM suggests CNS infection

90% remain positive if tested within 8 days on symptom onset


Wnv antibody diagnosis1

WNV Antibody Diagnosis

Asymptomatic pts common

In endemic area, IgM could be high

Acute, convalescent titres

Viral culture low yield

Real-time PCR:

55% CSF positive, 10% serum


Wnv encephalitis pt outcome

WNV Encephalitis Pt Outcome

Overall, 4-14% mortality

Age > 70, 15-29% mortality

DM, immunosuppression also predict worse outcome


Wnv encephalitis prevention

WNV Encephalitis Prevention

Reducing the # of vector mosquitoes

Draining standing water sites

Methoprene spraying (no maturation)

Adulticides (organophos, pyrethroids)

Prevent mosquito bites

50% DEET, 10% DEET in children

Permethrin to clothing, fabrics

Citronella (less effective)


Key learning points

Key Learning Points

AMS, fever, weakness: encephalitis

Know clues for West Nile virus

Early use of ceftriaxone, acyclovir

Supportive care essential

Consultation for best diagnostics

Reportable public health disease

Prevention is best approach


Questions
Questions?

www.FERNE.org

edsloan@uic.edu

312 413 7490


ad