A case of altered mental status

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A case of altered mental status

• J. Stephen Huff, MD
• Associate Professor
• Emergency Medicine and Neurology
• University of Virginia
• Charlottesville, Virginia

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Lets talk about a case...

• 52 year-old man brought to ED by EMS
• CC Frontal headache

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History of Present Illness

• 3 weeks of frontal headache
• Seen by primary care physician 1 week ago
• Cranial CT obtained
• no intracranial abnormalities
• right maxillary sinusitis
• started on an antibiotic
  (amoxicillin / clavulanate)

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History of Present Illness1 day prior to ED visit

• Headache worsened
• Episodes blurred vision and confusion
• Seen again by primary care physician
• Switched antibiotic to moxifloxacin

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History of Present IllnessDay of ED visit

• Awakened 6 AM severe headache
• Falls or syncope or seizures?
• Agitated, confused, hallucinating?
• Arrived ED 0840 by EMS

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Past Medical History

• Psoriasis with vasculitis (digital ischemia)
• Non-insulin dependent diabetes
• Hypertension, coronary artery disease
• Current medications-
• Prednisone, celecoxib, metformin, glipizide,
  esomeprazole, candesartan, ASA, diltiazem,
  cyclobenzaprine, fluticasone / salmeterol inhaled

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Social history(after arrival of family later)

• Works as truck driver
• Married, lives with family
• Past smoker gt 40 pack-years
• Alcohol, drug use denied

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Physical examination

• Restless, agitated
• 147/86, p 96, RR 16, Temp 36.9
• SaO2 99 (room air)
• Will follow simple commands
• Responds with name
• Looking off into space

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Physical examination

• Difficult
• General examination unremarkable
• Digit amputations left hand
• Psoriatic plaques
• Chest clear no murmurs

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Patient description...

• Restless, agitated
• Rolling back and forth
• No consistent meaningful responses
• Neurologic examination
• moves all extremities...
• Pupils 4 mm, equal, reactive

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something not right

• Confusion
• Agitation
• Acute delirium
• Altered mental status

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Differential diagnosisinitial

• Withdrawal syndrome
• alcohol
• benzodiazepines
• Intoxication
• alcohol
• benzodiazepines

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Differential diagnosis

• Seizures
• post-ictal state
• non-convulsive status epilepticus
• CNS infection?
• CNS structural?
• Systemic infection?
• Metabolic disturbance
• ...may co-exist...

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Initial approach

• IV access
• Rapid glucose determination
• Thiamine
• Laboratory and other blood tests
• Sedation for safety?
• More history?

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Sedate the patient?What is your choice?

• a) midazolam (Versed) 4 mg IV
• b) lorazepam (Ativan) 2 mg IV
• c) haloperidol (Haldol) 5 mg IV
• d) fentanyl mcg IV
• e) avoid sedation if at all possible

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ED course....

• Family arrived-confirmed no history of drug or
  alcohol abuse pattern
• Family doubted ingestion
• Altered mental status worsening

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Laboratory results

• WBC 13,700 platelets 310, 000
• Na 132, bicarb 24. Cr 1.1 BUN 20
• Glucose 207 Lactate 1.6
• Urinalysis unremarkable
• Hepatic functions unremarkable

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Differential diagnosis revisited

• Withdrawal syndrome
• Intoxication
• Seizures
• post-ictal state
• non-convulsive status epilepticus
• CNS infection?
• CNS structural?
• Systemic infection?
• Metabolic disturbance

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Differential diagnosis revisited

• Withdrawal syndrome
• Intoxication
• Seizures
• post-ictal state
• non-convulsive status epilepticus
• CNS infection?
• CNS structural?
• Systemic infection?
• Metabolic disturbance

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Clinical Evidence

• Afebrile
• White blood cell count indeterminate
• Supple neck
• CT a week ago showed sinusitis

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a few words about Kernig et al

• Tests for neck rigidity and stiffness....
• What does supple mean, anyway?

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Jolt accentuation of headache maneuver
...bottom line...
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Pre-test probabilities?balancing act

• Acute bacterial meningitis?
• Other CNS infection?
• CNS structural lesion?
• brain abscess?
• parameningeal infection?

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CNS Infection?What is your choice for next step?

• a) empiric antibiotics
• b) cranial CT
• c) lumbar puncture
• d) MRI
• e) a, b, and c

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Working plan

• Presumed CNS infection....
• Concerned about possibility of brain abscess....
• Did not want to delay medical therapy

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What medication(s) would you give this patient?

• a) ceftriaxone or other cephalosporin
• b) vancomycin
• c) acyclovir
• d) dexamethasone
• e) all of the above

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• a) ceftriaxone - why?
• b) vancomycin - why?
• c) acyclovir - why?
• d) dexamethasone - why?

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Empiric therapy for suspected bacterial meningitis

• Laboratory-guided ?
• Age or risk-factor guided?

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Age-guided therapy for suspected bacterial
meningitis

• Ceftriaxone appropriate for all outside of
  neonatal period (gt3 months)
• Vancomycin for possible resistant S.
  pneumoniae
• Listeria possible at extremes of age
• add ampicillin if age less than 1-3 months or
  greater than 50 years

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Is encephalitis a possibility?Herpes simplex
encephalitis

• What are probabilities?
• Is timing as important?
• Should further tests be run? What?
• Empiric acyclovir?

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Steroids?

• Are steroids useful or important in acute
  bacterial meningitis?
• Dexamethasone studies...

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Steroids in acute bacterial meningitis

• Conflicting studies through the years
• Most recent - 301 adults with acute bacterial
  meningitis
• randomized
• 10 mg dexamethasone 15-20 minutes before
  antibiotics
• 10 mg every 6 hours for four days
• Reduction of adverse outcomes and death (26 v.
  52)
• Greater benefit in most ill patients....

De Gans et al (NEJM 2002 3471549)
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What medication(s) would you give this patient?

• a) ceftriaxone or other cephalosporin
• b) vancomycin
• c) acyclovir
• d) dexamethasone
• e) all of the above

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CT first?

• Risk of deterioration after LP in presence of
  mass lesion?
• pre-test probability?
• risk factors?
• adequate exam?

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LP

• Lumbar puncture attempted with difficulty
• Procedural sedation restraints
• Initial attempts failed.....options?

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LP options

• Fluoroscopy?
• Is it important now in this case?
• after all, broad antibiotic coverage...
• a) acceptable to defer LP until later time?
• b) go forward at all costs to get fluid?
• c) defer for moment revisit later?

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What we did....

• Ceftriaxone, Vancomycin (0915)
• Acyclovir
• Dexamethasone (1211)
• Invited consultants to be involved
• Sedation for protection and CT
• Procedural sedation and restraints
• With effort obtained clear, colorless CSF

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CSF results

• 117 red blood cells
• protein 119
• glucose 56
• 121 white cells
• 22 segmented, 77 lymphocytes

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What type of CNS infection does this patient have?

• a) bacterial meningitis
• b) viral meningitis
• c) encephalitis
• d) another CNS infection
• e) cannot tell with certainty

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Call from laboratory...

• Requesting India Ink test
• 3 encapsulated yeast

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Fungal meningitis...

• Cryptococcus neoformans most common
• Amphotericin or other therapy?

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Fungal meningitis...

• Induction with amphotericin B
• Longer term therapy with fluconazole
• Liposomal amphotericin
• CSF pressures....

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MRI

• Additional imaging obtained....
• Rule out small masses
• Rule out parameningeal involvement

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Case Conclusion

• Admitted to ICU
• Amphotericin given
• Others discontinued following studies
• Rapid improvement in confusion
• MRI- extensive sinusitis

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Case Conclusion

• Repeat LP - OP 27--gt11 cm H2O
• Home on intravenous amphotericin
• (then to fluconazole)
• Persistent headaches

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Case Conclusion

• Headaches thought to be from ICP
• Improved following VP shunt

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Cryptococcus neoformans

• 1/100,000 in non-HIV infected population
• Chronic, sub-acute, or acute
• Encapsulated yeast
• Steroid use

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Final thoughts

• Empiric therapy just that, empiric
• Transition to definitive therapy
• Unusual presentation of unusual diseases...
• Correct diagnosis often needed for correct
  therapy

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Final thoughts

• Think treatable causes
• Do not delay therapies of treatable causes for
  diagnostic tests....
• Empiric therapy for bacterial meningitis
• Dexamethasone

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Questions?

• J. Stephen Huff, MD
• jshuff_at_virginia.edu