60/M ALTERED SENSORIUM 2°TO ?ACUTE ISCHEMIC STROKE ?MENINGITIS
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CHEIF COMPLAINTS AND HOPI.
A 60 year old male who is a resident in telangana ,he does a cotton business. Came to the casualty in altered sensorium on 30/04/2023.
Patient was apparently asymptomatic 10 years back then he developed fever and went to a ayurvedic doctor and was found to be having retroviral postive.
And started using herbal medicine for that and the symptoms he was experiencing back then was subsided.
1month back patient developed weakness in his left hand with tingling and numbness sensation which is insidious in onset and gradually progressive in nature with no aggravating and releiving factors for that he visited the same previous Ayurveda doctor and started using some herbal medicine prescribed by him and then, 3to 4 days later, he developed fever (on and off) and no chills and rigors, which is insidious in onset and gradually progressive in nature along with the fever he also started experiencing leg (both the legs)pain and weakness as well as flank pain for which he went to the same Ayurvedic doctor and he got a scan done the doctor told him that he had stones in his kidneys and prescribed some herbal medicine with dolo and multivitamin tablets. But after this also the fever did not subsided so they again went to him (Ayurvedic doc) 10 days back and the doctor adviced some investigations and after that he told that his viral load is high and prescribed herbal medicine which are of high dose and after using this high dose herbal medicine for 4 to 5 days the patient developed dysphagia and pain in the throat which is insidious in onset and gradually progressive in nature (dysphagia initially to solids and then later to liquids).
He also developed cough 4 days back which is insidious in onset and gradually progressive in nature no history of weight loss,no history of night sweats and after that his responsiveness was decreased and now presented with altered sensorium.
PSYCHOSOCIAL HISTORY: This patient has a friendly relationship with his family friends as well as neighbors
PAST HISTORY:
Know case of HIV POSTIVE since 10 years
Known case hypertensive since 3 years.
Not a known case of DM2,ASTHMA,EPILEPSY,TB,CAD.
DAILY ROUTINE:
He does cotton business.
He daily wakes at 5 Am and takes bath and fresh up drinks tea at 7am and then he takes his breakfast (RICE with vegetable curry )at 8am and goes for his business and comes at 1 pm and takes his lunch which consisting of a vegetable curry and rice and after his lich he chit chat with his neighbors and lie down for some time and after that he watch TV and then eats his dinner at 8pm and goes to sleep at 9pm.
Family history:No similar complaints in the family .This old man has 4 childern(2 sons and 2daughters) and his wife died 5 years ago due to some health issues.
PERSONAL HISTORY:
DIET:VEGETERIAN
APPETITE:DECREASED SINCE 2 MONTHS
BOWEL BLADDER :NOT PASSING STOOLS SINCE 4 DAYS.
SLEEP:ADEQUATE
ADDICTIONS:HE STARTED TAKING BEER 15 DAYS BACK FROM THIS ILLNESS FOR 10 DAYS.
GENERAL EXAMINATION:
Patient is drowsy but arousal.
GCS:E2V1M5
BP:130/80mmhg.
PR:110/min
RR:18CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 99°F
PALLOR PRESENT,no icterus,cyanosis,clubbing,lymphadenopathy and edema
SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :NORMAL SIZE AND NON REACTIVE.
TONE: RT. LT
UL HYPER. HYPER
LL HYPER. NORMAL
POWER:
UL 2/5. 2/5
LL 2/5. 2/5
REFLEXES:
B: 3+ 3+
T: 2+ 2+
S: 2+ 2+
K: 2+ 3+
A: 1+ 1+
P: EXTENSORS
CLINICAL IMAGES AND INVESTIGATIONS
30/04/23
MRI IAMGES SHOWING INFARCTION:
MRI VIDEO OF THIS PATIENT SHOWING
INFARCTS:
https://youtube.com/shorts/8_EAcNzgLik?feature=sh
CT VIDEO OF THIS PATIENT:
https://youtube.com/shorts/Ln_hfm9gEgE?feature=share
PROVISIONAL DIAGNOSIS:
RETROVIRAL POSTIVE (10 YEARS)
☆ALTERED SENSORIUM 2°TO? ACUTE ISCHEMIC STROKE(RECURRENT)
?MENINGITIS (?TB)
TREATMENT:
•IVF- NS @50ml/hr
•RYLES FEEDING:100ml water 2nd hourly
200ml milk 4th hourly.
•TAB ECOSPIRIN 150mg/RT/STAT
• TAB ATROVASTATIN. 40mg/RT/STAT
FOLLOW UP
.................................
01/05/2023
S:
FEVER SPIKES PRESENT
STOOLS NOT PASSED .
O:
On examination
Patient is drowsy but arousal.
GCS:E1V1M3
BP:130/80mmhg.
PR:140/min
RR:18CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE: RT. LT
UL HYPER. HYPER
LL HYPER. HYPER
POWER:
UL 2/5. 0/5
LL 2/5. 0/5
REFLEXES:
B: 2+ 2+
T: 2+ 2+
S: 2+ 2+
K: 2+ 3+
A: 1+ 1+
P: EXTENSORS
A:
ALTERED SENSORIUM 2°TO ?MENINGITIS,2°TO ?TB,?ACUTE ISCHEMIC STROKE. RETROVIRAL POSTIVE (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .
P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY.
PLANNING FOR CBNAAT.
PLANNING FOR LUMBAR PUNCTURE
02/05/2023
S:
5 FEVER SPIKES SINCE YESTERDAY 8AM
STOOLS NOT PASSED .
O:
On examination
Patient is drowsy but arousal.
GCS:E1V1M3
BP:110/80mmhg.
PR:140/min
RR:22CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE: RT. LT
UL HYPER. HYPER
LL HYPER. HYPER
POWER:
UL 2/5. 0/5
LL 2/5. 0/5
REFLEXES:
B: 2+ 2+
T: 2+ 2+
S: 2+ 2+
K: 2+ 3+
A: 1+ 1+
P: EXTENSORS
A:
ALTERED SENSORIUM 2°TO ?MENINGITIS,2°TO ?TB,?ACUTE ISCHEMIC STROKE. RETROVIRAL POSTIVE (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .
P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY
WORKSDONE:
LUMBAR PUNCTURE DONE AND CSF SAMPLES WERE SENT FOR CSF ANALYSIS, CSF SUGAR PROTEIN AND
CBNAAT SAMPLE WAS SENT
BUT ..
The reports of csf analysis and sugar protein says there is no meningitis...This report says there is no meningitis!
Can it still be tubercular meningitis?
Can tubercular meningitis present with hypoglycorrhacia and increased proteins alone inspite of normal cells in CSF?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5893425/
Acellular CSF was also commonly reported among other HIV-infected microbiologically-confirmed TBM!!
03/05/2023
S:
3 FEVER SPIKES SINCE YESTERDAY 8AM( at 4pm,5pm,10pm)
STOOLS NOT PASSED .
O:
On examination
Patient is drowsy but arousal.
GCS:E2V2M3
BP:130/90mmhg.
PR:98/min
RR:26CPM
SPO2:96%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE: RT. LT
UL HYPER. HYPER
LL HYPER. HYPER
POWER:
UL 2/5. 0/5
LL 2/5. 0/5
REFLEXES:
B: 1+ 1+
T: 1+ 1+
S: 1+ 1+
K: 1+ 1+
A: 1+ 1+
P: EXTENSORS
A:
ALTERED SENSORIUM 2°TO ? TB MENINGITIS,RETROVIRAL POSTIVE (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .
P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
TAB:ISONIAZID 5mg/kg.PO/OD
Tab:RIFAMPICIN 10mg/kgPO/OD
TAB;PYRAZINAMIDE 25mg/kgPO/OD
TAB:ETHAMBUTOL 15mg/kg PO/OD
TAB:BENADON 40mg po/OD
INJ:DEXA 6mg iv/tid
Inj:PANTOP 40mg iv
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY.
WORKS:
CBNAAT REPORT WILL BE UPDATED TOMORROW .MEAN WHILE WE ARE STARTING HIM ANTI TUBERCULAR THERAPY EMPIRICALLY.PLANNING TO SEND SAMPLES FOR INFLAMATORY MARKERS.
QUESTIONS IN THE ROUNDS :
1●WHY IS DEXAMETHASONE BEING USED EVEN
WHEN THE PATIENT IS IMMUNOCOMPRIMISED???
2•WHY ARE WE NOT USING ANTIFUNGALS?
3•WHAT ARE THE MARKERS OF INFLAMMATION???
Inflammation is the body’s innate response to injury
Certain proteins are released into the bloodstream during inflammation,if their concentrations increase or decrease by at least 25%, they can be used as systemic inflammatory markers they
also known as acute phase reactants, those most commonly used in clinical practice are C-reactive protein (CRP), erythrocyte sedimentation rate (ESR).
4•HOW DOES THE STEROIDS WORKS ON THE CELLS??https://pubmed.ncbi.nlm.nih.gov/12084906/#:~:text=Steroid%20hormones%20regulate%20cellular%20processes,nucleus%20to%20alter%20gene%20expression
5•WHAT IS THE REASON FOR HIS COMA??
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/
Tuberculous meningitis (TBM) is still a crippling disease with a high degree of morbidity and mortality. One of the most severe complications of TBM is stroke resulting from vascular involvement. In HIV-infected individuals with TBM, the immune response to the tuberculous bacilli is altered; therefore, pathological features are very different from those seen in patients with relatively normal cell-mediated immunity (CMI). The brains of such individuals showed minimal inflammatory response with parenchymal infarcts and vasculitis, not only in the basal ganglia but in the cortical parenchyma as well.
https://www.cambridge.org/core/books/uncommon-causes-of-stroke/vasculitis-and-stroke-due-to-tuberculosis/ACB91EF45660A1B7AAD98C17E3DE2701
On examination in rounds the patient eyes looks like dolls eye that mean the cortex of the patient is not working but the patent bthebrainstill working but he is not arousable
SUMMARY::
Diagnosis :
Retroviral chronic illness 10 years
Altered sensorium 3 days
Quadriparesis
To rule out intracranial space occupying lesion or chronic meningitis
Respiratory failure type 1 on o2 with right upper lobe cavitory lesions
History :
60 year old Man from Telangana presented with altered sensorium one day and quadriparesis for a month (initially hemiparesis).
On clinical examination he had :
GCS:E2V1M5
BP:130/80mmhg.
PR:110/min
RR:18CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 99°F
PALLOR PRESENT,no icterus,cyanosis,clubbing,lymphadenopathy and edema
SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :NORMAL SIZE AND NON REACTIVE.
TONE: RT. LT
UL HYPER. HYPER
LL HYPER. NORMAL
POWER:
UL 2/5. 2/5
LL 2/5. 2/5
REFLEXES:
B: 3+ 3+
T: 2+ 2+
S: 2+ 2+
K: 2+ 3+
A: 1+ 1+
P: EXTENSORS
Course in hospital :
His respiratory failure was tackled with oxygen therapy and HRCT was planned to investigate further the right upper lobe cavities visible on chest X-ray as well as cranial MRI was planned to investigate his focal neurodeficits which is showing infarcts in right frontoparietal and temporal area and altered sensorium with CSF with India InK stain.
