UCI MICU Case Presentation

HPI CC: HA, fever, weakness, and nausea x 2 days HPI: 58 y/o M who presented to UCI ED 8/3: pt. developed headache w/ photophobia and phonophobia that resolved with Tylenol 8/4: Patient received HD which was followed by nausea, restlessness and fatigue and he then became agitated & restless 8/5: Presented to UCI’s ED

PMHx ESRD 2/2 diabetic nephropathy with LUE AVF, HD MWF Anemia 2/2 ESRD IDDM Uncontrolled HTN Diastolic HF with EF 63% (3/5/14) Pancytopenia Surgeries LUE AVF 2010 Amputations= R 2nd toe (2011), L 1st toe (1995)

Meds/Allergies/FHx/SHx Renelva 1600 mg TID Phoslo 667 mg 2 tablets TID Metoprolol 100 mg BID Clonidine 0.1 mg TID Amlodipine 5 mg 4 times per wk on non-HD days Ranitidine 150 mg qday Tradjenta 5 mg qday Lantus 14 u qday Allergies: NKDA FHx: h/o DM2 in both sides of family. No renal issues or cancers. SHx No EtOH, smoking, IV drugs lives at home in Santa Ana with family and is retired

ED Course VS: T 102.5, P 85, BP 183/90 R 16 O2 98on RA Gen: sick, vomiting x1 during interview, altered, AOx2, states year is 1940 HEENT: nc/at, anicteric sclera, MMM, EOMI, PERRL Cardio: RRR, +S1, S2, no m/r/g, no JVD, no carotid bruits. Palpable thrill in R radial artery from AVF. Pulm: CTAB, no w/r/r, normal work of breathing GI: +BS, soft, nt/nd, no hepatosplenomegaly Skin: no c/c/e Neuro: face symmetric, equivocal sensation in cranial V1,2,3 distribution, 5/5 facial strength, tongue midline, puffs cheeks, smiles. Intention tremor present on finger to nose test. No pronator drift. Musc: 5/5 muscle strength in all major muscle groups of BUE and BLE.

Labs

Labs cont’d

CXR

ED Course CT Head: LP was attempted and aborted 2/2 agitation No evidence of acute intracranial hemorrhage, mass effect or hydrocephalus LP was attempted and aborted 2/2 agitation Patient admitted to family medicine

Hosp Course 8/5: 8/6: Started on Vanc/Zosyn for possible pneumonia LP planned for next day Plans for MRI 8/6: Patient with worsening rigors, fevers and AMS Primary team concerned for meningitis vs endocarditis vs pulm embolism Patient transferred to MICU and abx coverage changed to Vanc, Cefepime, Ampicillin, Acyclovir LP performed

CSF Results WBC added = WBC blood x RBC CSF/RBC blood 1 WBC for every 750

Labs/Cultures: HIV: negative Coccidioides IgG/IgM: negative Crypo antigen: negative Mycoplasma IgG/IgM: negative Histoplasma: negative Pregnancy test: Negtaive Cultures Sputum (8/7):  NGTD Bld cx (8/4): NGTD Repeat bld cx (8/6)-AVF: NGTD

CSF Cultures Enterovirus: negative Viral culture: no virus isolated VZV: negative Bacterial culture: NGTD Fungal culture: negative Acid fast bacillus (TB): negative Cryptococcus: negative HSV1/2: negative

Hosp Course 8/6: Tonic clonic seizure like activity observed Loaded with Keppra EEG: Moderate degree of generalized cerebral dysfunction with no epileptiform abnormalities

4 days later

West Nile Meningoencephalitis Diagnosis… West Nile Meningoencephalitis

West Nile Virus Symptoms develop in 30-40% of those infected Life long immunity Incubation period: 2-14 days Longer among immunosuppressed patients Common presentation: low grade fever, headache, malaise, back pain for 3-6 days before presentation Can present as meningitis vs encephalitis vs acute flaccid paralysis 25-50% of patients develop a rash Can lead to acute flaccid paralysis Maculopapular involving the chest, back and arms and lasts for less than a week; associated with less invasive disease

West Nile Virus Diagnosis: IgG + IgM CSF and serum Plasma West Nile virus RNA CSF: Pleocytosis with lymphocytic predominance Increased protein Normal glucose CT head usually reveals no acute findings MRI shows increased sign intensity in brain stem EEG shows generalized, continuous slowing IgM seroconversion occurs in 4 days and IgG in 8 days Plasma RNA 9 days

West Nile Virus Treatment: Prognosis: Supportive measures IVIG: Been suggested as possible therapy; however, no evidence to support its use Prognosis: 30-40% of patients achieve full recovery at 12 months 30-40% fatality rate 30-40% will have long term neurological deficits Long term neurological sequela: fatigue, word finding difficulty