1. CLINICAL PROBLEM SOLVING
A man with slurred speech and changes in behaviour
Vladimir Krajinovic, MD, PhD

2. History Your next step:
51-year old male was admitted to the hospital ER due to depressed level of consciousness and confusion
On that day he acted strange and had slurred speech
When ER arrived to his home the patient had secondary generalized tonic-clonic seizures
He was treated with 10 mg of diazepam iv at home and transferred to hospital
Your next step:
Detailed history and clinical exam, CT head and basic lab
CT head scan and basic lab
brain NMR and basic lab
Detailed history, clinical exam, brain NMR, basic lab, bloodcultures
c+d

3. Correct answer:
Detailed history and clinical exam, CT head and basic lab
CT head scan and basic lab
brain NMR and basic lab
Detailed history, clinical exam, brain NMR, basic lab, bloodcultures
c+d

4. History and clinical exam
Previously healthy, except arterial hypertension
Fever of 38.5 °C was noticed in clinical exam and postictal confusion
He had no sings of hemiparesis
During observation the patient had many generalized seizures that were treated with diazepam
Bloods were taken for analysis A brain CT was performed – normal, except mild oedema
Your next step: a) bloodculture b) Brain NMR c) Bloodculture and lumbar puncture d) Chest X-ray e) All above

5. Correct answer:
a) bloodculture b) brain NMR c) bloodculture and lumbar puncture d) chest X-ray e) all above

6. Lumbar puncture CSF – clear, normal pressure Cell count: 192/3 mcL
93% mononuclears
Proteins: 0.93 g/L
Glucose: normal
From CSF findings, clinical picture and CT scan your diagnosis is the following: a) Bacterial meningoencephalitis b) Viral meningoencefalitis c) Brain abscess d) TBC meningitis e) All above

7. Correct answer:
a) Bacterial meningoencephalitis b) Viral meningoencefalitis c) Brain abscess d) TBC meningitis e) All above

8. The expected pathogen is:
a) enterovirus b) tick borne encephalitis virus c) herpes simplex virus d) HIV e) West Nile virus

9. Correct answer:
a) enterovirus b) tick borne encephalitis virus c) herpes simplex virus d) HIV e) West Nile virus

10. Patient menagement?
Empiric antimicrobial therapy: a) acyclovir as soon as possible b) acyclovir + ganciclovir as soon as possible c) acyclovir, but only after positive PCR from CSF d) acyclovir + ganciclovir, but only after positive PCR from CSF e) amphotericin B

11. Correct answer:
Empiric antimicrobial therapy: a) acyclovir as soon as possible b) acyclovir + ganciclovir as soon as possible c) acyclovir, but only after positive PCR from CSF d) acyclovir + ganciclovir, but only after positive PCR from CSF e) amphotericin B

12. Most important lab parameter to check during treatment:
complete blood count
liver enzymes
blood urea nitrogen, creatinin and electrolytes
glucose level
albumins

13. Correct answer: complete blood count liver enzymes
blood urea nitrogen, creatinin and electrolytes
glucose level
albumins

14. Treatment complication
After one week of treatment with acyclovir, non- oliguric acute kidney injury appeared. You decided to: a) stop treatment with acyclovir b) modify dose of acyclovir and continue treatment c) change therapy to valacyclovir d) continue acyclovir in the same dose e) none of above

15. Correct answer:
After one week of treatment with acyclovir, non- oliguric acute kidney injury appeared You decided to: a) stop treatment with acyclovir b) modify dose of acyclovir and continue treatment c) change therapy to valacyclovir d) continue acyclovir in the same dose e) none of above

16. Herpes simplex encephalitis (HSE)
Herpes simplex encephalitis (HSE) remains a serious illness with significant risk of morbidity and death.
HSE is the most common cause of sporadic viral encephalitis, with a predilection for the temporal lobes and a range of clinical presentations, from aseptic meningitis and fever to a severe rapidly progressive form involving altered consciousness.
Clinical features of HSE include fever with mental status changes (depressed level of consciousness, confusion, disorientation, personality changes) sometimes with seizures (focal or generalized), dysphagia, or other focal neurological signs.
Symptoms vary in intensity early in the disease, but tend to progress rapidly.

17. Herpes simplex encephalitis (HSE)
LP, CT and MRI can play an important role in determining the diagnosis and extent of the disease.
The prognosis for patients with HSE has been dramatically improved by the availability of specific antiviral therapy
Sequelae in surviving patients may include severe neurological deficits, seizures, and/or neuropsychological dysfunctions that greatly impair quality of life.
To improve the prognosis for patients with HSE, acyclovir treatment should be initiated as soon as HSE is suspected.
After discharge, rehabilitation should be provided, in the effort to improve the patient’s self-reliance in everyday life.