This case starts with a pretty common presentation to the emergency department: AMS. As with most cases of AMS in the ED, the patient had a CT head done during his ED course. However, our patient also had an MRI done before he left the ED. While MRI’s are typically not our bread and butter imaging technique, they can sometimes be essential to making the diagnosis.
A few more details to this case… The patient was a 54 yo man with no past medical history. In addition to AMS the patient presented with confusion and unresponsiveness for 2 days as well as a fever.
As usual, please post in the comments to request more details about the history, exam, labs, consults etc… The first post with the most accurate diagnosis will receive a prize!
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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nchristopher
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Looks like midbrain (pontine) infarct possibly causing central hyperthermia.
I would want to know the remainder of the neuro exam.
Can I get vitals, a venous blood gas with co-oximetry, comprehensive, serum osmolarity, lactate, glucose, ethanol, salicylate level, acetaminophen level, and rectal temperature?
Vitals 120/77, 96, 20, 101.2 (rectal)
BMP 136/ 3.9/ 99/ 23/ 8/ 0.66 < 122
LFT 6.0/ 3.3/ 39/ 37/ 41/ 0.3
Ca 7.9
Lactate 4
ETOH negative
APAP low
ASA low
Osm – not done
Neuro Exam (From Neuro consult):
MS: Pt does not follow commands, stares with eyes open
CN: Forcibly closes eyes, Fine nystagmus noted, No facial asymmetry
Motor: No spontaneous movements. Pt is rigid throughout. Does not withdraw from noxious stimuli, only grimaces
Reflexes: depressed throughout
Plantars: Downgoing B/L
Positive Kernig and Brudzinski
A little more Hx:
Pt had been complaining of generalized malaise, headache and photophobia. Two days prior to presentation, he worsened and had slurred speech, difficulty talking and an episode of convulsions with urinary incontinence. Wife also noted a “bump on his head” last week which “disappeared on its own”.
Given the hx… i think most of us would want CSF…
So here are the results:
CSF WBC 3
CSF RBC 4
CSF Glucose 55
CSF lactate 2.1
CSF Protein 73
CSF Gram stain: no organisms seen
I think that he has West Nile Encephalitis. They often have elevated protein and elevated WBC with lymphocyte predominance. In MRI studies of patients with West Nile Encephalitis they often have findings in the internal capsule. Due to the history of the bump and fever, ams and signs of meningitis with no bacteria seen. I would like to culture for West Nile or PCR if available.