Download Primary Care Conference Rebecca L Byers MD Clinical Case May

Primary Care Conference
May 25, 2005
Becky Byers MD
Guest patient Charlie Byers PhD
ENCEPHALITIS: An Inside
Account
Physician/Spouse
Professor/Patient
Clinical Case
Patient is now a 58 year old professor. He
had had a viral syndrome for approximately
one week, then on 3/6/03 felt feverish and
chilled; helped kids with homework, then
went to bed early.
Awoke 3/7/03 with mental status changes
including confusion and inability to answer
questions appropriately.
Past Medical History
Asthma, chronic; well-controlled on Advair
100/50 BID, albuterol prn (seldom needed).
Dyslipidemia (baseline HDL 18); on statin
and Niaspan.
Non-smoker.
No hypertension, DM.
ER and Stroke Team
Normal enhanced head CT without acute bleed.
IV Heparin.
Normal head MRI without evidence of acute
stroke or perfusion abnormality.
Normal MRA of the neck without evidence of
focal stenosis.
EEG - abnormal, but non-diagnostic.
Lumbar Puncture
Nucleated cells 7, 82% lymphocytes, 18%
macrophages. No RBCs.
Protein 70 (15-45)
Glucose 68 (40-80)
Gram stain - negative.
Admitted to Neuro ICU with probable viral
encephalitis.
Neuro ICU
Empiric IV ceftriaxone and ampicillin.
Empiric IV acyclovir.
ID Consult - recommended stopping
antibiotics; continue acyclovir 10 mg/kg
Q 8 hours.
Send CSF for viral culture, HSV PCR,
Enteroviruses, LCM, Mycoplasma, AFB/
fungal culture and smear.
Serology for coccidioidomycosis, HIV
ELISA, serum cryptococcal antigen,
Mycoplasma serology, Enterovirus, and
LCM serology.
CXR.
Consider repeat CSF if not improving over
next 24 hours.
Objectives
Brief review of causes of encephalitis.
Patient perspective of the illness and the
recovery process.
Living with uncertainty; the power/anxiety
of knowing/not knowing “the cause”.
Encephalitis
Infection involving brain parenchyma,
characterized by cognitive deficits.
20,000 annual viral cases in U.S.
Primary vs postinfectious (viral invasion vs
immune-mediated disease).
Often few, if any, CSF abnormalities with a pure
encephalitis (small increase in WBC/ lymphocytes
and protein concentration, normal glucose,
absence of RBCs).
Viral Infections of the CNS
Enteroviruses - Coxsackie A and B
Echoviruses
Polioviruses
Arthropod-borne viruses
West Nile virus
St. Louis encephalitis virus
California encephalitis virus
Eastern/Western e.v.
Herpesviruses - Herpes simplex 1
Herpes simplex 2
Cytomegalovirus
Varicella zoster virus
Epstein Barr virus
Simian herpes B virus
Other Viruses
HIV
Rabies virus
Lymphocytic choriomeningitis virus
Influenza virus
Mumps virus
Measles
Diseases Mimicking Viral CNS
Infections - Infectious Causes
Tuberculosis
Partially treated bacterial meningitis
Listeria meningitis
Spirochetal infection (syphilis, Lyme
disease, leptospirosis)
Rocky Mountain spotted fever
Fungal (cryptococcosis,
coccidioidomycosis, histoplasmosis)
Mycoplasma pneumoniae
Parameningeal infection (brain abscess,
epidural or subdural abscess)
Amebic infection
Trypanosomiasis
Toxoplasmosis
Cerebral malaria
Disseminated cat-scratch disease
Whipple’s Disease
Legionellosis
Noninfectious Causes
Tumor
Dural venous sinus thrombosis
Sarcoidosis
Cerebral vasculitis
Behcet’s disease
Drug-induced meningitis (NSAIDs, sulfa)
Migrainous syndromes with pleocytosis
Patient Perspective
Anomaly between patient’s ability to
understand vs communicate verbally.
Comprehension vs emotional response by
the patient; associated difficulty for family
and doctor to understand patient’s mental
state.
Patient Perspective 2
Prolonged nature of rehabilitation;
difference between test results and patient
perspective.
Effect on the patient of the expectation of
family and friends to be told definitive
etiology.