Current Dx: Meningoencephalitis of unknown etiology
Status: Waxing and Waning mental status, new onset seizures, hemodynamically stable
HPI: 41 yo woman doctor, formerly in good health, found unconscious in her call room after sufferring from a febrile illness approximately 1 week. She went on to suffer a series of seizures that evening. A spinal tap was performed which was consistent with a viral meningitis. Lymphocytes were predominant. JACK to find out exact results of 1st spinal tap. Pt. was tansported to BI Deaconess Hospital for further treatment. There she was started on Propofol and Keppra for anti-seizure Rx. She is on continuous EEG monitoring - so far activity c/w microseizures. She was placed on Acyclovir for anti-viral treatment and ___________ for anti-bacterial Rx. She had a head CT and MRI which were unremarkable. Tests so far that were (-) included enterovirus, EBV, Lyme, and Toxoplasmosis. Gram stain (-) and cultures (-).
Pending tests include EEE, CMV, West Nile, Parvovirus B19, Bartonella, Mycoplasma, Listeria.
HIV not done due to MA state law!
Pt. is currently unresponsive, recently intubated due to rising CO2. Her BP 110/70, HR 95 with no supportive therapy. CXR may have shown a small pneumonia.
PMH: 1) HSVI-occasional outbreaks
2) Pyelonephritis
PSH: 1) Strabismus surgery x 3
2) Fallopian tube removed due to cyst
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3 comments:
ID doc: I have a few comments and suggestions:
1. viral encephalitis: most places send an encephailitis panel to the state lab. I suspect one would have been sent and is pending>
2. even if a virus is identified, we have few therapies for these infections. we often use the information to tell families prognosis and time lines
3. she has been treated for herpes (on acyclovir). very appropriate, until proven not to be herpes...and some MDs will treat even if labs for herpes are negative.
4. we often see fever after a periord of 'getting better'. these fevers may be related to new infections like pneumonia, sinusistis, line infections or other issues. I suspect her current docs are looking into those.
5. on my list of other viruses causing encephalitis are CMV, and EBV. both of which bump your liver enzymes. conversely, a bump in liver enzymes may be realted to her anticonvulsants.
6. other non-infectious causes for seizures such as lupus and autoimmune illnesses and vasculitis illnesses must be investigated. I suspect this workup has already been sent.
7. I often have an optho eval as part of our encephalitis eval.
-hope this has been helpful
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