Infectious Disease Clinical Case Presentation Samina Syed, MS IV Kees Van Dam, MD September 12, 2007 CC: Acute mental status changes “I feel like I’m going crazy” History of Present Illness
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Samina Syed, MS IV
Kees Van Dam, MD
September 12, 2007
“I feel like I’m going crazy”
R.S. is a 19 year old white male in the Armed Forces, who was preparing for deployment to Iraq during the week of 9/3.
The patient’s family visited him over the weekend (9/1-9/2) and he was in a normal state of health aside from complaints of a headache.
On Monday, 9/3, his father called him around 1300 and was surprised to find him still in bed. His son sounded unusually sleepy.
That evening the patient told his mother that he with felt like he was “going crazy.”
On 9/4 he did not show up for work.
He was found on his bed nude, mumbling incomprehensible words.
He was taken to AF base facility and then to Wayne Memorial.
Upon admission, he could state his first name and the year.
He began showing signs of frontal disinhibition and rapidly deteriorated.
He underwent lumbar puncture and was placed on ceftriaxone, vancomycin, and acyclovir.
He was intubated for airway protection and transferred to MICU at UNC.
Upon arrival patient was minimally responsive to noxious stimuli.
SOCIAL HX: Active duty stationed at a nearby airforce base. Deployment week of 9/3/07. Per coworkers, patient does not drink, smoke, or do illicit drugs.
Travel: Patient trained in Texas November-April and then moved to North Carolina. He visited family in NY state in July.
FAMILY HX: No hx of early CAD
HOME MEDICATIONS: mefloquine
General: Intubated, no response to voice.
Lymphadenopathy: 1 mm left axillary node
Skin: Two to three 1 mm areas with blanching papules bilaterally on the feet. Similar papules were on the dorsum of PIP on left hand and DIP of ring finger on left hand.
Comatose, no response to voice
Visual fields show no reaction to threat bilaterally, PERRLA
Normal bulk and tone, bilateral upper extremity extensor posturing with nail pressure
Slight withdrawal on left lower extremity with nail pressure, slight movement of right quadricep with right lower extremity naill pressure
Reflexes symmetric and 3+ bilaterally at bicep, tricep, bracheoradialis, patellar, ankle.
LP: opening pressure 36
Appearance: colorless clear
28% neutrophils 59% lymphocytes, 13% monocytes,
Glucose 65, Protein 91.
CSF Gram stain: No organisms, few WBCs
CT with and without contrast: showed “no acute intracranial process and no enhancing lesions.”
An MRI was performed at Wayne Memorial prior to transfer.
MRI also performed at UNC on evening of arrival to MICU.
There are large areas of abnormal T2 and FLAIR signal abnormalities involving the subcortical and deep white matter in the bilateral frontal, parietal, and occipital lobes.
There is abnormal signal involving the the corpus callosum and periventricular white matter.
There is abnormal increased T2 and FLAIR signal involving the medial portions of the temporal lobes and right thalamus.
There is similar abnormal signal involving the posterior pons.
There is a somewhat linear area of restricted diffusion in the left frontal region just superomedial to the sylvian fissure. This correlates with an area of FLAIR and T2 signal abnormality.
There is abnormal FLAIR signal in the subarachnoid spaces bilaterally superiorly. This is nonspecific but can be seen with proteinaceous fluid or subarachnoid hemorrhage but can also be related to ventilation.
1.Multiple areas of abnormal signal involving predominantly white matter but also areas of gray matter.
2. Nonspecific increased FLAIR signal in the subarachnoid space as described above.
HIV negative RPR NR Crypto ag serum neg B12 normal
WNV (CSF) VZV PCR (CSF) HSV PCR (CSF) Lyme titer (CSF)
Crypto Ag CSF Fungal and AFB stain and culture (CSF)
A second LP at WM had been done on 9/4 with CSF and serum sent to CDC labs.
PCR negative CSF and Blood for poxvirus nucleic acid
Serum and CSF IgG negative for poxvirus
Serum and CSF IgM pending
CDC strongly endorsed adding IVIG to the high dose steroids.
Conference calls with the CDC were continued to follow the course of the post vaccinia complication: post vaccinial encephalitis.
Later that evening the serum and CSF IgM returned positive.
Despite lack of evidence for disseminated vaccinia, decided patient might benefit from vaccinia immunoglobulin and CDC shipped VIG overnight to RDU.
VIG started on Friday afternoon, IVIG resumed afterwards until pt completed 2g/kg over 4 days.
High dose steroids continued.
Vaccinia virus is a live DNA virus used as the vaccine against smallpox, which is caused by the Variola virus.
Day 3-5 Papule
Day 5-8 Vesicular
Day 8-10 Pustular
Day 14-21 Scab separation
Superinfection of the vaccination site or regional lymph nodes
Erythema multiforme major or SJS
Postvaccinial CNS disease
ie MRI etc were not available in 1920s, 1960s.
The overall incidence in the U.S. was 2.9/million vaccinees in 1968. The case fatality rate in the U.S. was 25% and 30-50% in Europe (1959-1966). In 2001, the CDC reported the rate as 1 case per 300,000 vaccinees.
Pooled summary of case fatality rates (CFR)