Transcript Case Study 37

Case Study 37
By Chris Sanders
History of Present Illness
 86 y.o. male
 Mosquito bite
 Swelling around right eye
 Bit 96 hours ago
 Severe periorbital edema
 Mild fever
 Mild headache
Review of Systems
 Alert and oriented
 Doctor suspects arthropod
 Follow up appointment with
neurologist and infections
diseases specialist
 OTC ibuprofen
 Ice to swollen area
Acute Viral Encephalitis
• What is the pathophysiology of swelling in this case?
• Why is the application of ice helpful to relieving
swelling in this case?
• Based on the patient’s location when he received the
mosquito bite, what are several possible diagnoses?
• Based on incubation period only, identify two potential
types of encephalitis in this patient.
• Are any of the infections that you listed above in your
answer to question 3 potentially serious?
Clinical Course
 Confused
 Disoriented
 Mild tremors
 Severe headache
Previous Medical History
 18 months S/P cadaveric
renal transplantation
 ESRD secondary to DM type
1, diagnosed 10 yrs
 CAD
 COLD x 6 yrs
 Asthma
 DM type 1 diagnosed at 13
Medications
 Nitroglycerin SR 6.5 mg po Q 8h
Blood
Glucose
(mg/dL)
Units @
breakfast
Units @
lunch
<80
4
-
-
-
 Albuterol MDI 2 puffs QID PRN
81-150
5
-
8
-
 Atrovent MDI 2 puffs BID
151-200
6
-
9
1
 Cyclosporine 250 mg po BID
201-250
7
2
10
2
 Prednisone 10 mg po QD
251-300
8
3
11
3
 Mycophenolate mofetil 1500 mg
301-350
9
4
12
4
351-400
10
5
13
5
>400
11
6
14
6
 Nitroglycerin 0.4 mg SL PRN
 Theo-Dur 100 mg po BID
po BID
 Insulin: NPH insulin 16 u @
breakfast and Lispro
Units @
supper
Units @
Bedtime
Three of the drugs listed above are of
particular concern in this patient. Which
three drugs should cause concern and
why should they cause concern?
 Nitroglycerin
 Dizziness, headaches,
lightheadedness
 Theo-Dur
 Dizziness, headaches,
lightheadedness
 Albuterol
 Dizziness, headaches
 Atrovent
 Headache, eye pain
 Cyclosporine/Prednisone
 Suppresses immune system
 Mycophenolate mofetil
 Suppresses immune system
PE and Lab Tests
 Disoriented, pale, mild
tremors, appears ill
 BP 150/95
 P 105 and regular
 RR 17 and unlabored
 T 100.5º F
 Warm and pale skin
 No rash observed
PE and Lab Tests Cont.
 PERRLA
 EOM intact
 Fundi reveal old laser scars
bilaterally w/o hemorrhages
and occasional hard exudates
bilaterally
 Ears and nose unremarkable
with no bulging of TMs
 Mucous membranes dry
 Mild non-exudative pharyngitis
present
 Wears dentures
PE and Lab Tests Cont.
 Thyroid normal
 Cervical and axillary lymph
nodes palpable (~2cm)
 Sinus tachycardia
 Chest normal
 Abd normal
 Rect normal
 Ext normal
PE and Lab Tests Cont.
 Disoriented
 Mild tremor in both hands
 DTRs 2+
 (+) Kernig sign
 (+) Brudzinski sign
 Muscular strength 3/5
 Decreased sensation in feet
(diabetic neuropathy)
• Suggest a reasonable explanation for the laser
scars in the eyes?
• Suggest a reasonable pathophysiologic
explanation for the patient’s enlarged lymph nodes.
• Although not routine practice, why were this
patient’s feet carefully examined for lesions?
• What is suggested by the positive Kernig and
Brudzinski signs?
Lumbar Puncture Results
 Significant lymphopenia
 Mild diffuse cerebral edema
with no intra-cerebral
bleeding
 Enzyme Immunoassay with
Plaque Reduction Neutralization
Test
 West Nile Virus
CSF
lymphocyto
sis
Normal
glucose
No CSF
RBCs
Moderately
elevated
protein
Normal
lactic acid
Gram stain
(-)
Bacterial
culture (-)
IgM antiviral
antibody (+)
• Based on all the available clinical
evidence above, what is a likely
diagnosis for this patient’s condition?
• What is an appropriate treatment
approach for this patient?