Download An elderly woman with nausea, vomiting, diarrhea, fatigue and chills

An elderly woman with
nausea,
vomiting,
diarrhea, fatigue and
chills
Case Presentation , DR M Haghighi MD
History of Present Illness
 A woman in her seventies was admitted to the hospital
because of nausea, vomiting, weakness, diarrhea,
abdominal pain, fatigue and chills.
 The patient had been well, with a history of diabetes
mellitus and vascular disease, until approximately 4
weeks before when, in mid-summer, she was scratched
and bitten numerous times on the arms, legs, and trunk
by a stray or feral cat she had taken in.
 She was seen at another hospital where amoxicillinclavulanate, a tetanus booster, and rabies vaccination
were reportedly administered, followed by additional
rabies immunizations on days 4, 7, and 14.
 She reported no subsequent warmth, swelling, pain, or
swollen glands in the arms, legs, axillae, or groin
following the incident.
 One week before this presentation, in late summer,
nausea, vomiting (without hematemesis), abdominal
pain, watery non-bloody diarrhea, anorexia, weakness
and fatigue developed, associated with intermittent
chills. She came to the emergency department. She
reported no known fever, headache, numbness, tingling,
dyspnea, chest pain or rash.
Past Medical History
 She had insulin-dependent diabetes mellitus (with
average capillary glucose levels of 160 mg/dl),
peripheral neuropathy, , hyperlipidemia, hypertension,
peripheral vascular disease with recent angioplasty in
the left leg, and chronic knee and wrist pain.
Medications
 Medications included diltiazem, valsartanhydrochlorothiazide, insulin, acetaminophen and
acetylsalicylic acid (81 MG).
Allergies
 She was allergic to sulfa, gemfibrozil, and
erythromycin, which had caused rashes.
Family History
 There was a family history of diabetes mellitus and
coronary artery disease.
Epidemiological History
 She did not smoke, drink alcohol or use illicit drugs. She
had not traveled recently.
Physical Examination
 She was fully oriented. The temperature was 101.4°F
(38.6°C), blood pressure 178/80 mm Hg, pulse 79 beats
per minute, respirations 18 per minute and oxygen
saturation 98% while breathing ambient air. There was a
grade 1-2/6 systolic ejection murmur at the left lower
sternal border, and heart sounds were otherwise
normal.
 The abdomen was soft, minimally tender to palpation in
left lower quadrant, without masses, and there were
numerous scratches on her limbs and torso, without
erythema or fluctuance. During the physical
examination, she often repeated "I am tired" and "I can't
remember". The remainder of the examination was
normal.
Studies
 The white cell count was 12,500 per cubic millimeter
(reference range 4500-11,000; leukocytes 85%,
lymphocytes 11%, monocytes 4%), hematocrit 32.9% (ref
36.0-46.0); hemoglobin 11.8gm/dl (ref 12.0-16.0),
platelets 142,000 per cubic millimeter (ref 150-400).
Tests of coagulation were normal. The blood level of
sodium was 133 mmol/L (ref 135-145), potassium 3.1
mmol/L (ref 3.4-4.8), carbon dioxide 22.4 mmol/L (ref
23.0-31.9), glucose 166mg/dl (ref 70-110) and urea
nitrogen 26mg/dl (ref 8-25); the estimated glomerular
filtration rate was 57mL/min/1.73m2 (ref abnormal if
<60 mL/min/1.73m2).
 Levels of chloride, calcium, phosphorus, magnesium,
lactic acid, creatinine, were normal. Testing for
antibodies to platelet factor 4 was negative. Urinalysis
revealed 2+ glucose and protein, with few bacteria and
squamous cells.
 Computed tomography (CT) of the abdomen and pelvis
with the administration of intravenous contrast was
normal.
 Culture of the stool grew normal enteric flora, without
evidence of enteric pathogens. There was no evidence
of Clostridium difficile toxin, protozoa, or helminth
ova, and cultures of the blood and urine were sterile.
 She was admitted to the hospital. Intravenous fluids
were administered for rehydration, and her other
medications continued, with gradual improvement in
most symptoms. Fatigue persisted, and on physical
therapy evaluation, tremulousness and loss of balance
were noted. On the fourth day, a neurological
consultant obtained additional history that increased
tremor was present for one week, and she had recent
mid-to-lower back pain that did not radiate, without
bowel or bladder incontinence, headache, neck stiffness
or photophobia.
 On the fifth day, computed tomography (CT) of the head
without the administration of contrast revealed central
volume loss and chronic microvascular changes, without
evidence of acute disease. Magnetic resonance imaging
(MRI) of the lumbosacral spine with the administration
of gadolinium showed focal T11-12 disc enhancement,
thought to be related to degenerative joint disease,
without abnormal enhancement.
CT of the brain, without contrast.
 A lumbar puncture was performed; analysis of the
cerebrospinal fluid revealed a glucose level of 99 mg/dl
and total protein level 26 mg/dl, with 20 white cells per
cubic millimeter (96% lymphocytes and 4% monocytes)
and 4 red cells per cubic millimeter in Tube 1. Gram
stain of the CSF showed very few mononuclear cells and
no organisms.
 Infectious disease consultation was obtained. Her
relatives reported that her speech was slower and wordfinding difficulties more severe than at baseline, and
that she had been relatively confused on admission,
with partial improvement since admission.
 Testing for antibodies (IgM) to Eastern Equine
encephalitis (EEE) was negative. Testing of the CSF for
Herpes simplex virus (types 1 and 2) DNA and
enterovirus RNA was negative, as was testing the blood
for antibodies to Bartonella henselae and Bartonella
quintana (IgG and IgM) and Treponema pallidum.
Culture of the CSF was sterile. Stool specimens were
negative for C. difficile toxin and viruses.
What is the diagnosis?
 Testing of the CSF for West Nile virus (WNV) IgM and the
West Nile virus plaque reduction neutralization test was
positive, compatible with recent infection.
Final Diagnosis
 Meningoencephalitis caused by West Nile virus.