NYU Medical Grand Rounds Clinical Vignette

Glenn Dym, MDPGY3

Tuesday, April 24th, 2012

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• 26 year-old Asian woman presents with acute-onset altered mental status associated with loss of consciousness

Chief Complaint

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•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 tonic-clonic movements of all four extremities.

History of Present Illness

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•At this point, the family called EMS, and the patient was brought in by ambulance to Bellevue Hospital for further management.

History of Present Illness

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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

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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

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Laboratory Findings

•CBC: Hemoglobin 11.1g/dl (12-16)•Remainder of CBC was within normal limits

•Basic Metabolic panel:•Sodium 124meq/L (137-147)•Potassium 3.2meq/L (3.6-5.2)•Chloride 91meq/L (99-112)•Bicarbonate 20meq/L (23-32)•Glucose 214 mg/dl (70-99)•Remainder of basic was within normal limits

•Hepatic panel was within normal limitsUNITED STATES

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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

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Other Studies

•ECG: 1st degree AV Block (PR 256) and R>S in V1,V2

•Head CT: no acute intracranial injury

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• 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

Working Diagnosis

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• 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.

Hospital Course

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• 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.

Hospital Course

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• 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

Hospital Course

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• Acute HSV-1 Encephalitis

Final Diagnosis

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