An 19 year old boy with fever, headache and paraparesis
The patient was a 19 years old male student. He presented to KEMH with a low grade fever since 10 to 12 days, without any localizing symptoms. He had a history of headache since then. He developed weakness of both lower limbs since 3 days (Left > right); initially he could not move his lower limbs and later could not turn in bed. He developed weakness of both upper limbs 1 day later. Having maintained sensorium for the previous 10 days, he began to become progressively disoriented since the last one day. There is a history of urinary incontinence since 3 days. He had no sensory complaints. There was no previous history of significant illness.
On admission to the hospital, the patient was afebrile, normotensive, had mild pallor, and a small tender splenomegaly (2 cm). Heart was normal, no S3, S4, murmurs. He was drowsy, responding to oral commands. His gag reflexes were impaired, extraocular movements were impaired. Pupils were reacting and bilaterally equal. Fundus was normal. There were no signs of meningeal irritation. He was hypertonic, the power in right UL was 4/5, left UL was 3/5, Rt LL was 2/5 and Lt LL was 1/5. The reflexes in UL were 3+ and in the LL were 4+. He had both plantars extensors. The chest X- ray was normal, ECG showed ST depression and T wave inversion in V2- V6. The images from the plain and contrast enhanced MRI examination of the brain are here (750KB PowerPoint presentation) The general condition of the patient worsened over the next 12 -16 hours in the ward. The patient had become extremely dyspneic and developed high grade fever. The respiratory rate was 44/min, BP = 100/50 mmHg. He had developed B/L extensive coarse crepitations, no BBS. His power had reduced and was 0/5 in all 4 limbs. In view of the respiratory distress, patient was shifted to MICU. Patient was intubated immediately and put on ventilator. The patient was investigated. Hb – 8.9 g/dl, Tc- 67,000 cells/dl, DLC – P15 L4 E 81. Platelet count – 2.4 lakhs/dl, Absolute eosinophil count – 54,513 cells/dl. Creatinine -1.5 mg%, BUN – 32, SGOT – 32 u/dl, SGPT – 35 U/dl. ALP – 44 U/dl, Na – 133 mEq/dl, K – 4.3 mEq/dl. Urine analysis – WNL. The patient was put on high dose steroids (methylprednisone – 1g/d) for his weakness and was started on injectable Piperacillin and Tazobactum on transfer to MICU. The patient was also started on Acyclovir and Artesunate, however were stopped on 3rd day. A repeat chest X – Ray revealed infiltrates in right lower and middle lobes. A complete hemogram of patient was done on the third day. Hb – 8.9g/dl, Retic – 3%, MCV – 84.9 fl, PCV – 28.7, TC – 45,200 cells/dl, DLC – (P18, L8, E70, M2), AEC – 31,640 cells/dl, No abnormal cells. Progress of patient – Inspite of high dose steroids the patient’s weakness did not improve. The patient continued to remain febrile. His oxygen requirement increased by the 3rd day. The patient was maintaining oxygen saturation on SIMV (FiO2 – 0.3) for 2 days. He however at this stage did not require any inotropes. The antibiotics were stepped up, Meropenem and Teicoplanin was started. A hematology reference was taken on the 3rd day. BCR/ABL test from peripheral blood was advised, however due to financial condition of the family, test was deferred. The patient was started on Tab. Imatinib. In view of the altered sensorium, a CSF examination was done. Polymorphs -3; Lymphocytes - 5, Protein - 16, Sugar 65, ADA -1.98, no eosinophils on smear. Blood culture did not grow any organism. Meanwhile, by the 5th day, the patient deteriorated. He had become hypotensive and his urinary output had dropped. The patient required high dose noradrenaline. Sepsis was overwhelming; the patient went into ARDS and expired on the 8th day of admission.
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CPC 1. 20.3.2009 |