2. OVERVIEW  acute onset and fluctuating symptoms  disturbance of consciousness (including inattention)  at least one of the following:  Disorganised thinking,  Disorientation,  Memory impairment or perceptual disturbance  Evidence of a putative causal medical condition DSM-IV criteria

3. FIGURE 156-3 Diagnosis of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). CDNOS, cognitive disorder not otherwise specified. Walsh: Palliative Medicine 1st edOVERVIEW

4. “The Scream” by Edvard Munch (1893).OVERVIEW

5. CASE PRESENTATION  A 74-year-old man with known hypertension and benign prostatic hyperplasia  presented with a 1-week history of fever.  The patient received amoxicillin and paracetamol  Four days later the patient became confused and refused to take the treatment orally.  confused, disoriented and hypoactive.  Pulse rate was 102 bpm, temperature 37.9°C and blood pressure was 150/70 mmHg.  The rest of the examination was unremarkable  The rest of the examination was unremarkable  there was no focal neurological deficit

6.  WBC 4.1/mm 3  WBC 4.1/mm 3  urine analysis : 6–12 pus cells per HPF  ESR : 45 mm in the first hour.  Serum electrolytes, renal and liver functions : normal  CT scan brain : normal. CASE PRESENTATION

7. Serology for HIV, brucella and salmonella were negative. However, serology for dengue fever was positive. The patient’s consciousness level deteriorated and fever continued WBC decreased to 2.45/mm 3 streptococcus group D from urine sensitive to cefipime The patient was started on cefipime 2 g every 12 hours. Ultrasonography confirmed prostatic enlargement Ultrasonography confirmed prostatic enlargement As treatment of UTI ? CASE PRESENTATION

8. Protein = 0.9 g/l Protein = 0.9 g/l total cell count = 45 (90% lymphocytes). Cultures, latex and acid-fast bacillus staining were negative in the CSF. Polymerase chain reaction for dengue was negative and the patient’s condition deteriorated. Work-up for underlying malignancy was inconclusive. Work-up for underlying malignancy was inconclusive. CASE PRESENTATION

9. Repeat CT was reported normal except for mild dilatation of ventricle MRI without contrast was normal However, contrast- enhanced MRI revealed peculiar ring enhancing lesions CASE PRESENTATION

10. OVERVIEW

11. OVERVIEW Sepsis-induced delirium, dengue meningo-encephalitis, toxoplasmosis and neurocysticercosis. Antibiotics, anti-tubercular medication and dexamethasone. Improved and is on regular follow-up.

13. DISCUSSION

14. DISCUSSION

15. DISCUSSION but they did not control for potential confoundersbut they did not control for potential confounders associations between delirium and cortical atrophy but the data were limited and somewhat inconsistentbut the data were limited and somewhat inconsistent reduced regional cerebral blood flow

16. DISCUSSION

17. DISCUSSION

18. Conclusion

19. Learning points underlying serious illness can present with delirium Imaging for the brain must be selected on case by case basis. Tuberculomas may involve any part of the brain tissue without focal neurological deficits.