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A case of altered mental status. J. Stephen Huff, MD Associate Professor Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia. Let’s talk about a case. 52 year-old man brought to ED by EMS CC: Frontal headache +. History of Present Illness.

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a case of altered mental status
A case of altered mental status

J. Stephen Huff, MD

Associate Professor

Emergency Medicine and Neurology

University of Virginia

Charlottesville, Virginia

let s talk about a case
Let’s talk about a case...
  • 52 year-old man brought to ED by EMS
  • CC: Frontal headache +
history of present illness
History of Present Illness
  • 3 weeks of frontal headache
  • Saw primary care physician 1 week ago
  • Cranial CT obtained
    • no intracranial abnormalities
    • right maxillary sinusitis
    • started on an antibiotic
      • (amoxicillin / clavulanate)
history of present illness 1 day prior to ed visit
History of Present Illness1 day prior to ED visit
  • Headache worsened
  • Episodes blurred vision and confusion
  • Seen again by primary care physician
  • Switched antibiotic to moxifloxacin
history of present illness day of ed visit
History of Present IllnessDay of ED visit
  • Awakened 6 AM severe headache
  • Falls or syncope or seizures?
  • Agitated, confused, hallucinating?
  • Arrived ED 0840 by EMS
past medical history
Past Medical History
  • Psoriasis with vasculitis (digital ischemia)
  • Non-insulin dependent diabetes
  • Hypertension, coronary artery disease
  • Current medications-
    • Prednisone, celecoxib, metformin, glipizide, esomeprazole, candesartan, ASA, diltiazem, cyclobenzaprine, fluticasone / salmeterol inhaled
social history after arrival of family later
Social history(after arrival of family later)
  • Works as truck driver
  • Married, lives with family
  • Past smoker > 40 pack-years
  • Alcohol, drug use denied
physical examination
Physical examination
  • Restless, agitated
  • 147/86, p 96, RR 16, Temp 36.9
  • SaO2 99% (room air)
  • Will follow simple commands
  • Responds with name
  • Looking off into space
physical examination11
Physical examination
  • Difficult
  • General examination unremarkable
  • Digit amputations left hand
  • Psoriatic plaques
  • Chest clear; no murmurs
patient description
Patient description...
  • Restless, agitated
  • Rolling back and forth
  • No consistent meaningful responses
  • Neurologic examination
    • moves all extremities...
    • Pupils 4 mm, equal, reactive
something not right
something not right
  • Confusion
  • Agitation
  • Acute delirium
  • Altered mental status
differential diagnosis initial
Differential diagnosisinitial
  • Withdrawal syndrome
    • alcohol
    • benzodiazepines
  • Intoxication
    • alcohol
    • benzodiazepines
differential diagnosis
Differential diagnosis
  • Seizures
    • post-ictal state
    • non-convulsive status epilepticus
  • CNS infection?
  • CNS structural?
  • Systemic infection?
  • Metabolic disturbance

...may co-exist...

initial approach
Initial approach
  • IV access
  • Rapid glucose determination
  • Thiamine
  • Laboratory and other blood tests
  • Sedation for safety?
  • More history?
sedate the patient what is your choice
Sedate the patient?What is your choice?

a) midazolam (Versed) 4 mg IV

b) lorazepam (Ativan) 2 mg IV

c) haloperidol (Haldol) 5 mg IV

d) fentanyl mcg IV

e) avoid sedation if at all possible

ed course
ED course....
  • Family arrived-confirmed no history of drug or alcohol abuse pattern
  • Family doubted ingestion
  • Altered mental status worsening
laboratory results
Laboratory results
  • WBC 13,700 platelets 310, 000
  • Na 132, bicarb 24. Cr 1.1 BUN 20
  • Glucose 207 Lactate 1.6
  • Urinalysis unremarkable
  • Hepatic functions unremarkable
differential diagnosis revisited
Differential diagnosis revisited
  • Withdrawal syndrome
  • Intoxication
  • Seizures
    • post-ictal state
    • non-convulsive status epilepticus
  • CNS infection?
  • CNS structural?
  • Systemic infection?
  • Metabolic disturbance
differential diagnosis revisited21
Differential diagnosis revisited
  • Withdrawal syndrome
  • Intoxication
  • Seizures
    • post-ictal state
    • non-convulsive status epilepticus
  • CNS infection?
  • CNS structural?
  • Systemic infection?
  • Metabolic disturbance
clinical evidence
Clinical Evidence
  • Afebrile
  • White blood cell count indeterminate
  • Supple neck
  • CT a week ago showed sinusitis
a few words about kernig et al
a few words about Kernig et al
  • Tests for neck rigidity and stiffness....
  • What does supple mean, anyway?
pre test probabilities balancing act
Pre-test probabilities?balancing act
  • Acute bacterial meningitis?
  • Other CNS infection?
  • CNS structural lesion?
    • brain abscess?
    • parameningeal infection?
cns infection what is your choice for next step
CNS Infection?What is your choice for next step?

a) empiric antibiotics

b) cranial CT

c) lumbar puncture

d) MRI

e) a, b, and c

working plan
Working plan
  • Presumed CNS infection....
  • Concerned possibility of brain abscess....
  • Did not want to delay medical therapy
what medication s would you give this patient
What medication(s) would you give this patient?

a) ceftriaxone or other cephalosporin

b) vancomycin

c) acyclovir

d) dexamethasone

e) all of the above

slide31
a) ceftriaxone - why?

b) vancomycin - why?

c) acyclovir - why?

d) dexamethasone - why?

empiric therapy for suspected bacterial meningitis
Empiric therapy for suspected bacterial meningitis
  • Laboratory-guided ?
  • Age or risk-factor guided?
age guided therapy for suspected bacterial meningitis
Age-guided therapy for suspected bacterial meningitis
  • Ceftriaxone* appropriate for all outside of neonatal period (>3 months)
  • Vancomycin for possible resistant S. pneumoniae
  • Listeria possible at extremes of age
    • add ampicillin if age less than 1-3 months or greater than 50 years
is encephalitis a possibility herpes simplex encephalitis
Is encephalitis a possibility?Herpes simplex encephalitis
  • What are probabilities?
  • Is timing as important?
  • Should further tests be run? What?
  • Empiric acyclovir?
steroids
Steroids?
  • Are steroids useful or important in acute bacterial meningitis?
  • Dexamethasone studies...
steroids in acute bacterial meningitis
Steroids in acute bacterial meningitis
  • Conflicting studies through the years
  • Most recent - 301 adults with acute bacterial meningitis
    • randomized
    • 10 mg dexamethasone 15-20 minutes before antibiotics
    • 10 mg every 6 hours for four days
  • Reduction of adverse outcomes and death (26% v. 52%)
  • Greater benefit in most ill patients....

De Gans et al (NEJM 2002; 347:1549)

what medication s would you give this patient37
What medication(s) would you give this patient?

a) ceftriaxone or other cephalosporin

b) vancomycin

c) acyclovir

d) dexamethasone

e) all of the above

ct first
CT first?
  • Risk of deterioration after LP in presence of mass lesion?
    • pre-test probability?
    • risk factors?
    • adequate exam?
slide42
LP
  • Lumbar puncture attempted
  • Procedural sedation + restraints
  • Initial attempts failed.....options?
lp options
LP options
  • Fluoroscopy?
  • Is it important now in this case?
    • after all, broad antibiotic coverage...

a) acceptable to defer LP until later time?

b) go forward at all costs to get fluid?

c) defer for moment; revisit later?

what we did
What we did....
  • Ceftriaxone, Vancomycin (0915)
  • Acyclovir
  • Dexamethasone (1211)
  • Invited consultants to be involved
  • Sedation for protection and CT
  • Procedural sedation and restraints
  • With effort obtained clear, colorless CSF
csf results
CSF results
  • 117 red blood cells
  • protein 119
  • glucose 56
  • 121 white cells
    • 22% segmented, 77% lymphocytes
what type of cns infection does this patient have
What type of CNS infection does this patient have?

a) bacterial meningitis

b) viral meningitis

c) encephalitis

d) another CNS infection

e) cannot tell with certainty

call from laboratory
Call from laboratory...
  • Requesting India Ink test
  • 3+ encapsulated yeast
fungal meningitis
Fungal meningitis...
  • Cryptococcusneoformans most common
  • Amphotericin or other therapy?
fungal meningitis50
Fungal meningitis...
  • Induction with amphotericin B
  • Longer term therapy with fluconazole
  • Liposomal amphotericin
  • CSF pressures....
slide51
MRI
  • Additional imaging obtained....
  • Rule out small masses
  • Rule out parameningeal involvement
case conclusion
Case Conclusion
  • Admitted to ICU
  • Amphotericin given
  • Others discontinued following studies
  • Rapid improvement in confusion
  • MRI- extensive sinusitis
case conclusion55
Case Conclusion
  • Repeat LP - OP 27-->11 cm H2O
  • Home on intravenous amphotericin
  • (then to fluconazole)
  • Persistent headaches
case conclusion56
Case Conclusion
  • Headaches thought to be from ICP
  • Improved following VP shunt
cryptococcus neoformans
Cryptococcus neoformans
  • 1/100,000 in non-HIV infected population
  • Chronic, sub-acute, or acute
  • Encapsulated yeast
  • Steroid use
final thoughts
Final thoughts
  • Empiric therapy just that, empiric
  • Transition to definitive therapy
  • Unusual presentation of unusual diseases...
  • Correct diagnosis needed for correct therapy
final thoughts61
Final thoughts
  • Think treatable causes
  • Do not delay therapies of treatable causes for diagnostic tests....
  • Empiric therapy for bacterial meningitis
  • Dexamethasone
questions
Questions?

J. Stephen Huff, MD

jshuff@virginia.edu

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