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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.