case 4 : 26F altered sensorium headache
26 year old female with complaints of altered sensorium since 1 day,headache since 8 days,fever and vomitings since 4 days,
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A 26 year old female who is a mother of two children, a tailor and agricultural labourer got married 10 yrs back
After 1yr she had male child of 10 yrs age and on 2 nd yr of her marriage she had female child of 8 yrs age.
In (2014 ) 6 yrs back she had bilateral hands small joint pains,later to elbow and shoulder for which she used medication prescribed by a local medical shop for 10 days,
(2017)3 years back,then she developed multiple joint pains she then visited local hospitals for a few months, later she got diagnosed with SLE in NRI hospital
since 1 month she has headache 1-2 times per week relieved on medication .but the headache worsened in the past 15 days ...she stopped using medication for SLE(one of which is methyl prednisolone) followed which she developed fever and headache along with neck pain.
Then she went to local hospital where she was admitted and at night when she went to washroom and did not return,then her mother went to check on her and noticed that she was lying on the floor with altered sensorium, then she presented to casualty with altered sensorium and irrelavent talk
c/o Heaeache since 8 days- in bitemporal vertex region
has been aggrevated since 1 week .
After stopping using steroids she has
fever since 4 days- low grade not associated with chills and rigors.
vomitings since 1 week (multiple episodes).
She has generalised weakness,decreased apetite and unable to walk for which admitted in nalgonda.
Neck pain since 4 days
At the time of presentation she has altered sensorium with irrelevant speech since 3 am in the morning
She was on medication for SLE (Hydrochloroquine-200mg/OD,Sulfasalazine,Methylprednisolone,Alandronic acid and Cholecalciferol,Aceclofenac,Flupirtine,Gabapentine,Methylcobalamin tablets), which she stopped 10 days back.
patient used to get low grade fever and joint pains when she missed her medications.
Not a k/c/o DM,HTN,Epilepsy,Asthma,TB,CVA
Family history: Her father in law has been active pulmonary Koch’s and finished his course of medication six months ago
General Examination:
Pt is drowsy, not coherent ,not cooperative
thin built
not oriented to time,place and person
vitals:
Temp- 98.3 F
BP-150/90 mmhg
PR- 56 bpm
RR-18 cpm
GRBS-134 mg/dl
SPO2- 98% at room air
Systemic examination:
CVS-S1S2 heard
RS-B/L air entry present
Per abdomen: shape- scaphoid
No tenderness, no palpable masses, liver and spleen not palpable
CNS:
Examination was done after 2 days when patient has become normal, prior the patient was in altered sensorium so the examination couldn’t be done
Intellectual functions:
patient oriented to time place person
Conscious+
Memory+
Orientation +
normal speech
Sleep normal
Gait: ataxic
Motor system
Right. Left
Bulk.
UL-
ForeArm 23 cms 23cms
Arm 23cms. 23 cms
LL-
Above knee
Tone UL- Decreased Decreased
LL- - -
Power-
UL- proximal 3/5. 3/5
Distal. 3/5. 3/5
LL- proximal- 5/5
Distal. 5/5
Hand grip- 30%. 20%
Reflexes Biceps Triceps supinator knee ankle
Right. +3. +3 +3. - -
Left. +3. +3 +3. - -
Superficial reflexes
Right Left
Corneal + +
Conjunctival + +
Abdominal + +
Plantars - -
Sensory: Right. Left
Lateral ST tract:
Temp: + +
Pain: + +
Anterior ST tract:
Pressure: + +
Crude touch: + +
Dorsal column:
Joint position. + +
Vibration. UL. N. N
LL - -
Fine touch. N. N
Cortical
stereognosis. N. N
Cerebellar
Dysdiadokinesia. -
Rhombergs. -
Tandem walking. -
Finger nose coordination +
Finger finger coordination. +
signs of neck stiffness - terminal neck rigidity present
Kernig’s sign: negative
Brudzinski’s- negative
[12/31/2020, 10:47 PM] Jabeen Kmni Intern: Case admitted today under unit 4 sir
[12/31/2020, 10:52 PM] Jabeen Kmni Intern: Hyponatremia under evaluation
[12/31/2020, 10:55 PM] Jabeen Kmni Intern: On admission Na was 120 meq/L . correction was given with 3% Nacl (250ml over 5 hours- approx 125meq )...serum Na rised to 131 meq/L then.
[12/31/2020, 10:56 PM]
Jabeen Kmni Intern: Serum osmolality-259 mosm/L
[1/1, 8:18 AM]
Rakesh Biswas Sir HOD: RDW CV - means common variant red cell distribution width.It measures changes in standard deviation in mean corpuscular volume
RDW- SD- means red cell distribution with standard deviation. Tells you about the variation in particle size by directly calculating from the RBC histogram. The more the RDW-SD the more the variation in red cell size
[1/1, 8:18 AM] Rakesh Biswas Sir HOD: The difference is only in the method in which red cell size distribution is calculated
[1/1, 8:22 AM] Rakesh Biswas Sir HOD: What was the outcome of the administration of 3% sodium? What improved? Did she become coherent and cooperative?
[1/1, 8:23 AM] Jabeen Kmni Intern: Yes sir, she is now able to identify her family members, place and all
[1/1, 8:23 AM] Jabeen Kmni Intern: And also she became coherent too
[1/1, 8:23 AM] Rakesh Biswas Sir HOD: What was the cause for her hyponatremia? Search SLE and hyponatremia and share
[1/1, 8:40 AM] Rakesh Biswas Sir HOD: So why is she losing sodium in her urine?
[1/1, 8:43 AM] Jabeen Kmni Intern: Hyponatremia could reflect severe inflammation and could be considered as one of the predisposing factors of fatigue.
[1/1, 8:43 AM] Jabeen Kmni Intern: She has CRP positive sir
[1/1, 8:45 AM] Rakesh Biswas Sir HOD: Yes but due you think her hyponatremia is due to a severe inflammatory response? Can you search and share if this is known with other inflammatory responses? This would again be something like a negative acute phase reactant discussed yesterday except that this is about an element rather than a protein?
[1/1, 9:21 AM] Jabeen Kmni Intern: The development of hyponatremia is associated with various inflammatory diseases including pneumonia, severe acute respiratory distress syndrome, tuberculosis, meningitis, encephalitis, human immunodeficiency virus infection, and malaria. However, the pathophysiology of hyponatremia diagnosed under these inflammatory conditions remains elusive.
Recent research revealed that inflammatory cytokines such as IL-1β and IL-6 are involved in the development of hyponatremia associated with inflammatory conditions, and that this process is related to ADH secretion
[1/1, 4:51 PM] Rakesh Biswas Sir HOD: Let's go ahead with CSF but remember to see the cells yourself asap along with the tech and get an estimate of the counts before the cells degenerate
[1/1, 7:47 PM] Usha Kmni Intern: Total count 5 cells/HPF
Lymphocytes 80%
Neutrophils 20%
Other cells nil
RBCs nil
[1/2, 4:54 PM] Rakesh Biswas Sir HOD: Tubercular encephalopathy without meningitis? 🤔
Sometimes I am terribly suspicious of CBNAAT specificity and this is one such occasion
Diagnosis:
The first on-call team thought it has euvolemic hyponatremia secondary to SIADH ..The second on-call team Decided to get MRI for this pt found acute stroke in left thalamus ...Later because of History and usage of Immunosuppressants ..the second on-call team also did CSF analysis which showed Positive for CBNAAT...thus we came to the diagnosis of TB Meningitis
Tubercular meningitis with k/c/o SLE since 3 years
CBNAAT positive-
On admission Na was 120 meq/L . correction was given with 3% Nacl (250ml over 5 hours- approx 125meq )...serum Na rised to 131 meq/L then.
Treatment on day 1:
1)NBM till further orders
2) Inj. pantop 40mg IV/OD
3)Inj.Zofer 4 mg/IV/TID
4)Temperature charting 2nd hourly
5)BP,PR,SP02, monitoring
6)IVF-3% NaCl
7) Repeat serum electrolytes every 4th hourly
8)Inj.ceftriaxone 2gm/IV/BD
9)T.methyl prednisolone 8mg PO/ BD
Treatment on day 2:
1)oral feeding with 100ml milk 2nd hourly
2) Inj. pantop 40mg IV/OD
3)Inj.Zofer 4 mg/IV/TID
4) Inj. ceftriaxone 2gmIV/BD
5)Temperature charting 4th hourly
6)BP,PR,SP02, monitoring 2nd hourly
7)strict input and output monitoring
8) GRBS monitoring 6th hourly
9)Inform SOS
10)Tab.Methyl prednisolone 8 mg PO/BD
11)Tab.Aspirin 75mg PO/OD
12)Tab.Clopitab 75 mg PO/OD
13)Tab.Atorvastatin 10mg HS
14)Inj.Mannitol100 mg IV stat
15)Tab.Paracetamol 500mg through RT
Treatment on day 3:
1)oral feeding with 100ml milk 2nd hourly
5)Tab.Aspirin 75mg PO/OD
6)Tab.Clopitab 75 mg PO/OD
7)Tab.Atorvastatin 10mg HS
8)Tab.Methyl prednisolone 8 mg PO/BD
9) Tab.Paracetamol 500mg through RT
10) Temperature charting 4th hourly
13)BP,PR,SP02, monitoring 2nd hourly
6)Tab.Aspirin 75mg PO/OD
7)Tab.Clopitab 75 mg PO/OD
8)Tab.Atorvastatin 10mg HS
9)Tab.Methyl prednisolone 8 mg PO/BD
10) Tab.Paracetamol 500mg through RT/SOS
11)syrup.cremaffin PLUS 15ml RT/TID
12)Inj.neomol 1g IV/SOS(only if temp >102 F
13)Tab.Benfomate PLUS RT/OD
14) Temperature charting 4th hourly
17)BP,PR,SP02, monitoring 2nd hourly
4)Tab.Aspirin 75mg PO/OD
5)Tab.Clopidogrel 75 mg PO/OD
8)Tab.Atorvastatin 10mg PO/OD/HS
9)Tab.Methyl prednisolone 8 mg PO/BD
10) Tab.Paracetamol 500mg through RT/SOS
11)syrup.cremaffin PLUS 15ml RT/TID
12)Inj.neomol 1g IV/SOS(only if temp >102 F
13)Tab.Benfomate PLUS PO/OD
14) Temperature charting 4th hourly
17)BP,PR,SP02, monitoring 2nd hourly
5)Tab.Aspirin 75mg PO/OD
6)Tab.Clopidogrel 75 mg PO/OD
7)Tab.Atorvastatin 10mg PO/OD/HS
8)Tab.Methyl prednisolone 8 mg PO/BD
9) Tab.Paracetamol 500mg through RT/SOS
10)syrup.cremaffin PLUS 15ml RT/TID
ECG:
USG:
2D ECHO:
