Come one, come all, and get your sleuthing caps on to figure out this months COtM.
You are doggedly working in the Janus Medical ED when a 72 y/o M with PMH HTN, CAD and prostate CA s/p radiation 5 years ago presents with 2 weeks of AMS. He answers yes and no to questions but cannot otherwise converse. He is accompanied by two sisters and his son. They report he lives alone and started having decreased appetite two months ago after having a viral URI. 2 weeks ago they noted mental status changes. He gets confused walking around the house and can no longer prepare food for himself. He now has trouble walking but no urinary incontinence. No h/o diarrhea or N/V. He was seen in another ED last week which sent labwork and discharged him home.
PE:
VS: HR 130, RR 12, BP 128/72, Temp 100.8F orally, 98% on RA
Exam negative aside from –
Constitutional: Dry MM, oriented to person and place unable to provide date
CV: Tachycardia w/o m/r/g, no edema in extremities
Neuro: Wide based magnetic gait
Skin: loose skin consistent with weightloss
Labs:
CBC:5.24>11.7/36<100, diff unremarkable
CMP: 162/3.7//120/29//33/0.93<100
Calcium: 13.6
T. protein: 6.7, Alb: 3.9, AST/ALT: 74/115, Alk Phos: 117
Lactate : 1.3
UA: negative bacteria, 0-5 wbc, neg nitritie, small leuk esterase, small ketones.
EKG shows sinus tachycardia at 132 w/o ST changes or abnormalities in interval lengths
A CXR is negative for effusions or infiltrates.
A CT Head only reveals enlarged b/l ventricles consistent with parenchymal volume loss.
Please answer the following questions:
- What is your differential diagnosis?
- What does your workup entail?
- How would you go about treating this patient?
Sound off below and good luck to all!
James Hassel
Latest posts by James Hassel (see all)
- Case Of the Month 11 – Answer - June 28, 2016
- Case of the Month 11 – Presentation - June 5, 2016
- Case Of the Month 10 – Answer - May 12, 2016
2 Comments
edenkim · September 12, 2015 at 2:36 pm
OK this one’s tricky and I’m probably wayyyy off and I should probably be sleeping now but here goes:
DDx:
NPH
anti-nmda receptor (or other autoimmune) encephalitis
other encephalitis
meningitis
paraneoplastic syndrome
ETOH
parkinson’s
prion disease
Workup:
-all that good stuff you already did
-LP for HSV, mycoplasma, opening pressure, gram stain, cell count, NMDAR, anti-neoplastic antibodies
-ESR, CRP, ANA, utox, ETOH level
-MRI head
-consider CT abd/pelvis to look for mets
-neuro consult
Tx:
-palliative consult
-if NPH, will need VP shunt
-IVF for the hypernatremia/calcemia, correcting slowly as it probably developed over weeks
-cardiac monitoring for possible autonomic instability
-given the tachycardia + fever, unlikely UTI or PNA, no mention of cellulitic findings, would treat presumptively for meningitis with vanc, ceftriaxone, ampicillin, acyclovir
-also consider IVIG and steroids for anti-nmda, but not as likely as this entity usually hit younger patients
eabram · September 13, 2015 at 3:04 am
SIRS in an older patient with AMS – I would certainly treat empirically in the ED with antibiotics and acyclovir until fever sorted out. But it’s more complicated than that:
This is also assuming his medication list is not the cause, he has no recent travel or exposures to bats, mosquitos, a rabid dog or anything else.
This patient has hydrocephalus (wide based magnetic gait, AMS). He also has suspected infection vs central fever vs inflammatory fever. Which came first? Fever or hydrocephalus?
There is hypercalcemia, hypernatremia, hyperchloremia, uremia, elevated AST/ALT (mild) but not ALP. T bili is not reported.
In addition to Eden’s excellent plan and diagnosis, I’d like to also suggest:
1. hydrocephalus from leptomeningeal carcinomatosis (specific neoplastic complication) with central fever. hx of prostate CA –> mets to skull common and spread to leptomeninges from skull not uncommon. Supported by hypercalcemia of disease, anorexia. Hypernatremia/hyperchloremia from dehydration from AMS, from central neurogenic process, from diabetes insipidus or from renal dysfunction. In his case, the leptomeningeal carcinomatosis is probably causing the diabetes insipidus. Also consider endocrine paraneoplastic such as adrenal/panhypopituitarism/thyrotoxicosis. The viral URI is 2 months in the past so it might be a red herring…. or it could be NMDA receptor encephalitis.
2. post-meningitic hydrocephalus
3. TTP – Fever, Anemia (he’s dry so he’s hemoconcentrated at 11), Thromocytopenia (functional from the aspirin he probably takes for his CAD), Renal (uremia and his Cr of 0.9 is a little high at his age and comorbidities), Neurologic (AMS, wide-based gait)
4. Cerebral venous sinus thrombosis (can cause obstruction and fever)
5. subdural or epidural hematoma or empyema
6. there’s always TB…
Other workup:
-hiv
-pth, spot cortisol, TFTs, serum osm, coags (elevated lfts?), tylenol level, asa level
-urine lytes, osm
-quantifuron (inpatient)
-o & p (inpatient)
-csf for fungal cultures (inpatient)
Diagnosing Leptomeningeal Carcinomatosis With Negative CSF Cytology in Advanced Prostate Cancer
Wendy B. Bernstein, Jean D. Kemp, Geoffrey S. Kim, and Viviana V. Johnson
JCO July 1, 2008:3281-3284