case 10 : 48M Altered sensorium - meningoencephalitis

 

thanks soumyadeep

https://127soumyadeepbiswas.blogspot.com/2021/07/a-case-of-48-yr-old-male-with-fever.html?showComment=1626189771717&m=1%23c4804821948814275408

July 2 , 2021

48 YR OLD MALE PATIENT DIAGNOSED WITH ALTERED SENSORIUM SECONDARY TO MENINGOENCEPHALITIS


CHIEF COMPLAINTS

  • Fever since 10 days

  • Altered sensorium  since 5 days

  • Weakness of bilateral lower limbs - 3days 


  • H/O of Oliguria since 3days


HISTORY OF PRESENT ILLNESS 


  • Patient was apparently  asymptomatic 1yr back , then he developed decreased urine output for which they admitted in hospital and Foley’s Catheter was placed , then he was diagnosed with Prostatomegaly with Rt renal calculi.


  •  Since 10 days patient has high grade fever on and off  not associated with vomiting/loose stools/cough.


  • Altered sensorium since 5 days.

  • Since 3 days patient had bilateral lower limb  weakness , difficulty to move B/L lower limbs associated with decreased urine output since 3 days. 


PAST HISTORY


  •  No H/O  hypertension , diabetes , asthma, TB , epilepsy


  • H/O HIV 10 yrs back


PERSONAL HISTORY


Diet - mixed


Appetite  - normal


Bowel , bladder movement - regular


Sleep - adequate


Regular smoker , alcoholic (occasionally 250ml)


FAMILY HISTORY


No relevant family history


GENERAL EXAMINATION


Patient is conscious , not coherent , not oriented to time place and person.


VITALS


BP: 130/90


Temperature: 101°F    


PR: 102 bpm 


Spo2: 98%










10-06-21


VITALS


Bp: 120/80 


PR: 100bpm








12-06-21


VITALS


Temperature:101.7 °F 


PR: 105bpm






  • Pallor - absent


  • Icterus - absent 


  • Cyanosis - absent


  • Koilonychia - absent 


  • Lymphadenopathy  - absent 


  • Clubbing  - absent 


  • Oedema - absent 


SYSTEMIC EXAMINATION 


CVS


  • Cardiac sounds S1 and S2 heard 


  • No cardiac murmurs heard


  • Thrills are absent




RESPIRATORY


  • Bilateral air entry with normal vesicular breath sounds heard 


  • No wheeze heard 


  • No dyspnea 


  • Trachea is central


ABDOMEN 


  • Shape of abdomen - Obese


  • No tenderness elicited


  • Palpable mass present


  • Free fluid is present 


  • Bruits can be heard


  • Liver and Spleen - Not palpable 


  • Bowel sounds - Present









CNS


  • Incoherent


  • Neck stiffness  


  • Kernig’s sign - Positive


  • Sensory -  cannot be examined


  • Motor -


                     R            L


Tone    UL   N            N (normal)    


             LL  decreased    decreased 


Power  UL   5/5            5/5


              L/L  1/5            1/5


REFLEXES


RT SIDED


biceps 2+ , triceps 2+ ,supinator 2+,knee absent, ankle absent 


LT SIDED 


biceps 1+, triceps 2 + , supinator 2+ , knee absent  ankle absent


No cerebellar signs 


PROVISIONAL DIAGNOSIS 


Altered sensorium secondary to Meningoencephalitis (infarct in splenium of corpus collosum)


INVESTIGATIONS 


(10-06-21)


CSF





RFT









BLOOD SUGAR








MRI BRAIN PLANS






CX-RAY 


ECHOCARDIOGRAM 





 





TREATMENT 



1 .inj PAN 40mg IV /OD


2 . IV NS/RL 75 ml/hr


3 .inj Thiamine 1 amp in 100ml NS IV/BD


4. Inj Optioneuron 1 amp in 100ml NS IV/OD


5 . Bp /PR/ Spo2 , temp monitoring 4th hourly


6. Tab ECOSPORIN Av 75/40mg OD



 TREATMENT UPDATE


  • inj PAN 40 mg /OD


  • IVF NS/RL 75 ml/hr


  • inj THIAMINE 100ML NS TID


  • inj OPTINEURON 10ML OD


  • TAB  CEFTRIAXONE 2gm /IV/BD


  • TAB ECOSPORIN -AV 75/40 mg /OD


  • GRBS charting 6th hourly



UPDATE  


(10-06-21)


  • Patient condition is improved , oriented to time place and person


  • By history it is found that , he is HIV positive since 10 + yrs


  • CSF analysis showed raised protein 2.9 gms and decreases glucose 28 mg/dl


  • CSF sent for culture.


  • Patient is started on inj  Ceftriaxone 



UPDATE  


(12 -06-21)


  • Patient is oriented to time , place and person


  • CSF analysis shows 40 percent lymphocytes 


  • CSF culture shows diptheroids


  • TB is considered one of differential diagnosis 


  • Anti tubercular therapy is yet to start


VITALS 


Temperature: 101.7 °F 


PR: 105 bpm












UPDATE 


(17-06-21)








TREATMENT UPDATE


Same treatment continued


+

Started on ATT  -HRZE REGIMEN 4 TAPO/OD


Started on HRT -TLD REGIMEN 1TAB PO /OD


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