e log
psmr
A case of 65 yr old came with the chief of
Vomitings since 5 days
Altered sensorium since 4 days.
Patient was apparently asymptomatic 7 months back when he suddenly developed pain in the low back and loin region for which he went to hospital and was diagnosed with Ckd .. but was only on maintainance medication since 7 months and
SINCE 1 month patient had history of intermittent head ache ,
FEVER intermittent, which was low grade , no evening rise of temperature ,not associated with chills rigors .
Headache was not associated with blurring of vision and diplopia .No history of ,giddiness ,photophobia and phono phobia .
Pt even has history of ? CAD , was on medication since 6 months .
Since 10 days patient had h/o loss of appetite and generalised weakness.
H/o vomittings since 5 days , 5-6 episodes/day, non bilious,non- blood stained, not associated with pain abdomen, loose stools, immediately after food intake.
So patient got admitted in local hospital on 13/06/20 where he was being treated for vomittings and dyselectrolytemia (hyponatremia).
From Next day of hospital admission patient was in altered sensorium. He had one episode of involuntary movements of upper and lower limb for about 2-3 min ,associated with uprolling of eye balls . Outside hospital CT brain was done which showed no significant abnormality .
No h/o tongue bite , frothing ,no h/o involuntary bowel and bladder movements.
Then pt was referred here in view of altered mental status on 18/06/20 at 3pm .
No H/O cough, SOB ,no h/o decreased urine output.
No h/o chestpain ,palpitations ,pedal edema ,no h/o burning micturition.
K/c/o ckd since 7 months on conservative management .
K/c/o HTN since1 yr
Not a K/c/o epilepsy, cva, TB , asthma in the past .
Pt is a toddy drinker 90ml/day since 30 years .stopped since 3months
Pt is chronic smoker since 30 yrs .5 beedis /day. Stopped 6 months ago .
General examination
Pt is drowsy , GCS - E4V1M4
Temp - Afebrile
Pr -90/min
Grbs - 109mgdl
Systemic examination
Cvs - s1,s2 heard
Rs -BAE present
CNS - PT DROWSY.
POWER - 3/5 3/5
3/5 3/5
TONE - N N
REFLEXES - B T S K A P
R - - - - +1 +1 MUTE
L- - - - - - MUTE
SENSORY SYSTEM AND CEREBELLUM COULDNT BE EVALUATED.
No neck stiffness .
Brudzinski sign present
No kernigs sign
P/a - soft, non- tender . Pt passed stools4 days back.
Investigations-
Hemogram
19/6 20/6 21/6 22/6 23/6 24/6
Hb 11 10 11.4 9.2 8.9 9.4
(gm / dl) Tc 22,200 13,600 13,700 15,700 18.1k 16.2k
Plts 3.66 1.84 2.28 2.33 2.0 1.85
Serum creatinine
2.7 2.3 2.7 3.2 3.4 3.1 Blood urea
108 94 100 118 129 123
Electrolytes
Na 140 131 129 134 138 K 3.3 3.0 3.7 4.5 4.4
Cl 102 95 94 101 102
ESR 80
Smear for MP negative ,
Hiv,hbsag ,hcv - negative.
Blood and urine ctures were negative .
Initially pt was treated with :
1)Inj .piptaz 4.5 gm IV BD
2) IVF 0.45 %NS and DNS @ urine output plys 30ml /hr .
3) Tab Amlong 10 mg /RT /OD .
4) Inj Levipil 500 mg IV BD
5) T. Ecosrpin AV 75/20 mg /HS /RT
6) Ryeles tube feeding - milk plus protein powder
7)Inj pan 40 mg /IV /OD
8) Inj Zofer 4mg /IV /TiD
Next day morning MRI brain was done which was showing obstructive hydrocephalus with ventriculitis .
Multiple acute infarcts in bilateral cerebellar hemispheres.
So pt was started on
inj ceftriaxone 2g/IV /tid
Inj Vancomycin 1g/IV /OD
Inj dexamethasone 8mg/IV /TID.
INJ MANNITOL 100ml IV /Tid .
T.Clopidogrel 75mg /RT / HS
Tab .Met xl 25mg /RT /OD
Rest same treatment continued (piptaz was with held)
On 21/6/20 -
morning 9am - PT DROWSY , pt had 3 fever spikes since past 24 hrs .
Bp - 150/100
Pr -132bpm
GCS -E2V1M3
RR-25/MIN .
Aound 11 am lumbar puncture was done which showed lymphocytic pleocytosis .
With decreased csf glucose and raised proteins .
Csf - no growth
Indian ink -no budding yeast cells seen.
No afb seen .
Same day in view of low gcs and respiratory distress patient was intubated and put on mechanical ventilator- ACMC -VC mode
Tv - 360 ml
Peep - 5cm of h2o
Fio2 - 100 %
Rr-16/min
Spo2 -99%
I:E -1:2
Bp - 140/100 mmhg
Pr - 140 bpm
Inj nor adrenaline was started at night in view of low blood pressure.
ATT was started from 22/06/20 - adjusted according to renal doses.
Gcs -3/15
Pupils 5mm - bilateral not reacting to light.
Deep tendon reflexes were negative and dollseye absent ,croneal reflex absent ,but gag reflex was present .
Next day -( 23/06/20) -
Pupils not reacting to light , corneal reflex absent ,gag reflex and cough reflex absent . Dolls eye movement absent .
Vestibo occular reflex tested by cold caloric testing - no nystagmus seen to opposite side.
No motor response to deep painful stimuli.
Same treatment continued.
24 /06/20 -PT had cardiac arrest - 3 cycles of cpr done. Pt was revived and connected back to ventilator.
CSF ANALYSIS
SUGAR:34
PROTEIN 56
CHLORIDE 118
ADA 6.5
CSF CYTOLOGY: Inflammatory lesion
Lymphocytes predominate
Csf : volume :1ml
Appearance :clear
TC:210
Lymphocytes:99%
Neutrophils:1%
Viral markers : anti HCV,HBsAg,HIV1/2 rapid test negative
PT 16 sec
INR 1.11
Aptt 33 sec
Serum iron 83
Blood c/s no growth after 24 hrs incubation
Urine c/s no growth after 24 hrs incubation
Csf no growth after 24 hrs incubation
MRI
