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    Copy-A CASE OF ALTERED SENSORIUM - ALOK

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    Alok Mohan
    The patient, a 79-year-old female, presented with fever, altered sensorium, involuntary movements and loss of consciousness for up to 17 days. Investigations revealed HSV-1 DNA in the CSF. A diagnosis of HSV-1 encephalitis was made. HSV-1 encephalitis requires prompt treatment with acyclovir to reduce mortality and morbidity, with better outcomes seen in those treated within 4 days of symptom onset.

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    Copy-A CASE OF ALTERED SENSORIUM - ALOK

    Uploaded by

    Alok Mohan
    60 views37 pages
    The patient, a 79-year-old female, presented with fever, altered sensorium, involuntary movements and loss of consciousness for up to 17 days. Investigations revealed HSV-1 DNA in the CSF. A diagnosis of HSV-1 encephalitis was made. HSV-1 encephalitis requires prompt treatment with acyclovir to reduce mortality and morbidity, with better outcomes seen in those treated within 4 days of symptom onset.

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    The patient, a 79-year-old female, presented with fever, altered sensorium, involuntary movements and loss of consciousness for up to 17 days. Investigations revealed HSV-1 DNA in the CSF. A diagnosis of HSV-1 encephalitis was made. HSV-1 encephalitis requires prompt treatment with acyclovir to reduce mortality and morbidity, with better outcomes seen in those treated within 4 days of symptom onset.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    60 views37 pages

    Copy-A CASE OF ALTERED SENSORIUM - ALOK

    Uploaded by

    Alok Mohan
    The patient, a 79-year-old female, presented with fever, altered sensorium, involuntary movements and loss of consciousness for up to 17 days. Investigations revealed HSV-1 DNA in the CSF. A diagnosis of HSV-1 encephalitis was made. HSV-1 encephalitis requires prompt treatment with acyclovir to reduce mortality and morbidity, with better outcomes seen in those treated within 4 days of symptom onset.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 37

    A CASE OF ALTERED SENSORIUM

    CLINICAL CLUB
    • 79 year old female

    Admitted on 22/04/2022
    Chief complaints:

    Fever - 17 days
    Altered sensorium – 17 days
    Involuntary movements – 16 days
    Loss of consciousness – 15 days
    • Developed an insidious onset, low grade,
    continuous fever without chills or rigor,
    subsiding with medication.
    • Fever persisting through course of illness,
    being present on most of the days
    • One episode of vomiting without nausea,
    containing food particles
    • On the same day the fever developed, son
    noticed a difference in personality of the
    patient.
    • Daily routine affected – skipping morning
    exercise, staring look, changed food
    preference
    • Speaking incoherently and at times engaging
    in conversations with herself
    • Taken to nearby hospital, next day developed
    involuntary tapping of right hand on bed with
    right knee movement.
    • Event lasted for about 15 minutes, patient
    being conscious throughout the event.
    • Lip smacking + during and after the event.
    • While being transported here, sensorium
    worsened, patient responding to calls and taps
    with moans.
    • Developed loss of consciousness as she
    reached our casualty, lasted for a few minutes
    after which she was unresponsive but kept her
    eyes open.
    • Patient on admission kept in ICU on ventilator
    support, preferably moved right side of body
    and persistenly looked towards left side.
    • At present patient is in ward, moves right side
    of body preferably.
    Past history
    • No history of comorbidities like DM, HTN, DLP,
    old PTB, CAD
    • H/o COVID-19 infection, Category B in March
    • Lumbar spondylosis – 30 years not on regular
    medication
    Personal history
    • Consumes non- vegetarian diet.
    • Increased sleep- daytime sleepiness, more
    towards the evening hours +
    • Patient after disease onset passes stools only
    once in 3-4 days
    • No history of addictions
    Menstrual history
    • Menarche at the age of 38
    • History of regular cycles with hypomenorrhea
    • Hirsutism +
    • Mother of 4 – normal vaginal delivery
    Family history
    • No significant history of illness in the family
    • Mother of 4 – 2 males and 2 females
    General Examination
    • E4V2M6
    • Patient moving all four limbs
    • No pallor/icterus/cyanosis/clubbing/
    lymphadenopathy/edema
    • Hyper pigmentation of palms +
    • Hirsutism +
    • No rashes or vesicles noted over the body
    Vitals
    • Pulse -rate : 86/’, regular, normal volume and
    character, no radiofemoral delay, all peripheral
    pulsations checked present bilaterally equal

    • BP : 100/60 mm Hg
    • Temperature: 99F
    • Respiratory rate : 21/’
    NERVOUS SYSTEM EXAMINATION
    Higher mental function :
    • E4V2M6
    • Patient is drowsy but arousable
    • Glabellar tap +
    • Pout reflex +
    CRANIAL NERVE EXAMINATION
    • CN I : Could not be tested
    • CN II : PEARL, b/l Pseudophakia
    • CN III,IV,VI : Left gaze preference +, Direct and
    indirect light reflex +
    • CN VII : WNL
    • CN IX, X : WNL
    Motor system
    • Normal bulk and tone
    • Paucity of movements of UL > LL
    • Reflexes
    RIGHT LEFT
    BICEPS JERK + +
    TRICEPS JERK + +
    SUPINATOR JERK + +
    KNEE JERK - -
    ANKLE JERK - -

    • Bilateral flexor plantar +


    • Sensory system and cerebellar signs could not
    be tested/elicited

    • Neck stiffness +
    • Kernig’s sign and Brudzinski sign -
    Other systems
    Respiratory system :
    • Air entry heard bilaterally equal
    • Crackles heard over right infra axillary and infra
    scapular area and left infra scapular area

    Cardiovascular system:
    • S1 S2 +, No murmur
    Gastrointestinal system :
    • Soft, no hepatosplenomegaly, bowel sounds +
    Provisional diagnosis
    • Non convulsive status epilepticus
    • Acute meningoencephalitis
    • ? HSVencephalitis
    • ? Aspiration pneumonia
    INVESTIGATONS
    22/04/22 24/04/22 26/04/22 01/05/22 04/05/22

    Hb 12.1 10.3 9.3 9.4 9.1


    Platelets 1.71 1.67 1.45 2.49 2.39
    Total Count 16.0 17.4 10.5 9.55
    DC 84.7/8.0/0.0 89.2/7.7/0.1 78.5/15.6/1.7 72.8/20.7/3.8 77.2/16.4/4
    ESR 26 134 55
    RFT 23/0.7 42/0.8 28/0.7 24/0.7 24/0.7
    Total/Direct 0.7/0.1
    bilirubin
    SGOT/SGPT 46/35
    ALP 64
    Total proteins 7.3
    S. Albumin 4.1
    S. Globulin 3.2
    Na+/K+ 124/2.9 123/2.7 125/3.9 131/3.6 128/4.1
    INR 1.00
    PERIPHERAL SMEAR
    CSF STUDY (23/04/22)
    • Protein – 42 (12 - 60)
    • Sugar – 75 (40 -70) [Blood sugar 184]
    • WBC – 20
    • RBC – 9
    • ADA – 1.74
    • Neutrophils – 1/20
    • Lymphocytes – 19/20
    • Gram stain and culture - Normal
    MRI STROKE SCREENING
    EEG (23/04/22)
    HSV DNA (25/04/22)
    DIAGNOSIS
    • HSV – 1 ENCEPHALITIS
    HSV ENCEPHALITIS
    • HSV-1 strains cause over 90% of cases of
    herpes simplex encephalitis (HSE) in adults,
    with the remainder due to HSV-2.
    • Conversely, HSV-2 is a more common cause of
    meningitis and neonatal meningoencephalitis
    than HSV-1.
    • Both HSV types 1 and 2 have been associated
    with myelitis.
    • Fever is present in about 90% and headache in
    about 80% of patients with biopsy or PCR
    proven HSE.
    • Disorientationtion (70%), personality change
    (70%–85%), focal or generalized seizures
    (40%–67%), memory disturbance (25%–45%),
    motor deficit (30%–40%), and aphasia (33%)
    • No sets of signs or symptoms are
    pathognomonic of HSE
    • CSF is usually under increased pressure, with a
    lymphocytic pleocytosis of 10 to 1,000 white
    blood cells (WBC) per μL. Over 95% of PCR or
    biopsy-proven cases of HSE have a CSF
    pleocytosis
    • The presence of red cells in CSF may be
    associated with a worse prognosis
    • CSF protein is usually moderately elevated and
    glucose is normal in more than 90% of
    patients with HSE.
    • Surprisingly, the HSV viral load is not a predictor
    of outcome
    • Approximately 90% of patients with PCR-proven
    HSE will have MRI abnormalities involving the
    temporal lobes
    • EEG may be abnormal early in the course of
    disease, demonstrating diffuse slowing, focal
    abnormalities in the temporal regions, or periodic
    lateralizing epileptiform discharges (PLEDs).
    • EEG abnormalities involving the temporal lobes
    seen in approximately 75% of patients with PCR-
    proven HSE
    • Empirical therapy with ACV should be started
    immediately in acute cases of focal
    encephalitis of suspected viral etiology

    • Mortality in untreated cases of HSE is around


    70%, but this is reduced to 19% to 28% in
    patients treated with ACV
    • Morbidity due to HSV-1 encephalitis remains
    high even in patients receiving ACV, with only
    37.5% of all patients surviving with no or only
    mild deficits
    • Survival and prognosis are influenced by
    several factors including level of consciousness
    at initiation of therapy (e.g., GCS), patient age,
    and duration of disease before therapy
    • In the CASG trial, all (9/9) patients treated with ACV
    within 4 days of onset of fever, headache, and focal
    neurological deficits survived, whereas the mortality
    was 35% in those in whom ACV treatment was
    initiated when disease was more than 4 days old
    • In another study, the recovery rate was 50% in
    patients treated within 5 days of illness onset.
    • In a third study of PCR-proven HSE, 75% of patients
    with an ultimately favourble outcome had received
    ACV therapy within 2 days of hospital admission
    compared to only 30% of those with a poor outcome
    • The standard adult dose of acyclovir for HSE is 10
    mg/kg, given intravenously (IV) every 8 hours (20
    mg/kg every 8 hours in neonates and children) for
    14 to 21 days.
    • Oral valacyclovir may be an alternative when
    intravenous acyclovir is unavailable
    • Retrospective studies have sug- gested that there
    may be some benefit in adding corticosteroids to
    ACV treatment
    • Foscarnet is an alternative therapy for patients
    with suspected or proven ACV-resistant strains or
    with allergy to ACV

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