Transcript Journal Club

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 tonicclonic 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
•Potassium 3.2meq/L
•Chloride
91meq/L
•Bicarbonate 20meq/L
•Glucose
214 mg/dl
(137-147)
(3.6-5.2)
(99-112)
(23-32)
(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