Abnormal movements in an unconscious adult Teaching NeuroImages Neurology Resident and Fellow Section © 2018 American Academy of Neurology.

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Presentation transcript:

Abnormal movements in an unconscious adult Teaching NeuroImages Neurology Resident and Fellow Section © 2018 American Academy of Neurology

Vignette An 80 year-old gentleman with a history of renal transplant, on tacrolimus, presented with fever (38.3 C) and confusion He rapidly progressed to unresponsiveness and was intubated for airway protection MRI demonstrated leptomeningeal enhancement, and CSF sampling identified varicella zoster by PCR Despite lack of sedation while intubated, he exhibited abnormal movements of the extremities whenever passively manipulated J. Siegler et al. © 2018 American Academy of Neurology

Video With passive wrist and finger extension, the patient exhibits sustained clonus of the right upper extremity. Similar observations were observed in the contralateral arm and in the ankles. J. Siegler et al. © 2018 American Academy of Neurology

Clinical finding: sustained clonus Encephalitis due to varicella zoster virus in this patient resulted in acute hyperreflexia Acute spasticity with pathologic hyperreflexia is an uncommon manifestation of several neurologic conditions including acute ischemic stroke, spinal cord injury, and infections of the central nervous system References K McCabe, K Tyler, J Tanabe. Diffusion-weighted MRI abnormalities as a clue to the diagnosis of herpes simplex encephalitis. Neurology 2003; 61(7): 1015-1016. J. Siegler et al. © 2018 American Academy of Neurology