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									     NYU Medical Grand Rounds
         Clinical Vignette

                                     Glenn Dym, MD
                                         PGY3
                                 Tuesday, April 24th, 2012




UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
                            Chief Complaint
• 26 year-old Asian woman presents with
acute-onset altered mental status
associated with loss of consciousness




 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                    History of Present Illness
•The patient was in her usual state of health
until the day of admission, when she noted a
mild headache and nausea in the afternoon,
which resolved with Tyenlol.
•Around dinner time, the patient was walking
with her family, and she suddenly collapsed to
the ground. Per the family, her eyes rolled to
the back of her head, she began foaming at the
mouth, and experienced generalized tonic-
clonic movements of all four extremities.

 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                    History of Present Illness
•At this point, the family called EMS, and the
patient was brought in by ambulance to
Bellevue Hospital for further management.




 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                   Additional History
•Past Medical History:
     •None
•Past Surgical History:
     •None
•Social History:
     •No known tobacco, alcohol or drug use
     •Patient lives with her family
•Family History:
     •Non-contributory
•Allergies:
     •No Known Drug Allergies
•Medications:
     •Tylenol prn


  UNITED STATES
  DEPARTMENT OF VETERANS AFFAIRS
                         Physical Examination

•General: patient appeared disoriented and
mildly agitated
•Vital Signs: T: 95.6°F BP: 106/51 HR: 84
RR: 15 and O2 sat: 100% on room air
•Neuro: alert but not oriented to person,
place, or time. Moving all limbs
spontaneously.
•Remainder of physical exam was normal
 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                           Laboratory Findings
•CBC: Hemoglobin 11.1g/dl (12-16)
    •Remainder of CBC was within normal limits

•Basic Metabolic panel:
  •Sodium        124meq/L              (137-147)
  •Potassium 3.2meq/L                  (3.6-5.2)
  •Chloride      91meq/L               (99-112)
  •Bicarbonate 20meq/L                 (23-32)
  •Glucose       214 mg/dl             (70-99)
    •Remainder of basic was within normal limits

•Hepatic panel was within normal limits
 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                           Laboratory Findings

•Prolactin: 43.8ng/ml (0-25)

•Creatine Kinase: 776U/L (35-155)

•Serum Osmolality: 247mosm/kg (277-302)

•Urine Osmolality: 332mmol (50-1000)
•Urine Sodium: 94meq/L
•Urinalysis: 2+ ketones

 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                  Other Studies

•ECG: 1st degree AV Block (PR 256) and
R>S in V1,V2

•Head CT: no acute intracranial injury




 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                             Working Diagnosis

• Syndrome of Inappropriate ADH leading to
  metabolic seizure due to hyponatremia
    – Etiologies considered include:
           • CNS Infectious (i.e. meningitis, encephalitis)
           • Toxic (i.e. drug overdose)
           • Occult malignancy




 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                  Hospital Course

• Hospital Day 1:
    – The patient received 1 dose each of
      vancomycin and ceftriaxone, and acyclovir
      was initiated empirically.
    – A lumbar puncture was performed which
      revealed 2 RBCs and 1 WBC, negative gram
      stain, glucose of 67mg/dl (40-80), protein
      25.5mg/dl (15-45); VDRL and HSV panels
      were sent and pending at this time.

 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                  Hospital Course

• Hospital Day 1:
    – The patient’s sodium auto-corrected to 141
      from 124 in less than 24 hours, and so the
      decision was made to transfer the patient to
      the MICU for more frequent sodium
      monitoring and D5W therapy.
• Hospital Day 2:
    – The patient’s sodium remained stable in the
      MICU for 36 hours, and her mental status
      improved to her baseline.
 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                  Hospital Course

• Hospital Day 3:
    – Patient transferred to the floor
    – Acyclovir discontinued
• Hospital Day 4:
    – Uneventful
• Hospital Day 5:
    – CSF HSV-1 results return positive
    – Acyclovir therapy reinstituted

 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS
                                  Final Diagnosis

• Acute HSV-1 Encephalitis




 UNITED STATES
 DEPARTMENT OF VETERANS AFFAIRS

								
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