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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.

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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


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



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 course17

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 course18

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






viral encephalitis etiologies

Viral Encephalitis Etiologies

Arboviruses: mosquitoes, ticks

Herpes viruses:

Herpes simplex



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 pathophysiology23

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


10% encephalitis rate if infected

150 to 3000 cases per year


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


Severe, fatal

16 cases between 1980-91; 8 US

Measles, influenza


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 encephalitis31

Arbovirus Encephalitis

Eastern equine

Western Equine

St Louis


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


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


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


Supportive therapies

Seizure Rx


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


Pre-existing neurological problem

Specific virus virulence

Coma does not = bad outcome

encephalitis pt outcome41

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 encephalitis44

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


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 diagnosis55

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




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