ALTERED MENTAL STATE

By Clare Di Bona

CASE 1. 25yo BIBA “Pseudoseizures” found slumped in a chair stiff,

LOC 2 minutes No post-ictal phase, no incontinence ED waiting room generalised seizure PMH depression on escitalopram. Has used

methamphetamine in the past GCS 11/15

Eyes open spontaneously 4 Groaning 2 Localising to pain 5

MRI Shows cerebral oedema

CASE 1. CSF

Appearance: clear and colourless Cell Count

Leucocytes 88/uL Polymorphs 1% Lymphocytes 99% Erythrocytes 2

Biochemistry Protein0.21g/L (0.15-0.45) Glucose 2.8 mmol/L (2.8-4.4)

Microscopy no bacteria seen Culture no growth High Anti-NMDA level

ANTI-NMDA ENCEPHALITIS Dropped GCS 3/15 in coma ICU Ongoing pseudoseizure activity with facial

twitching and finger movements Autonomic dysfunction persistent tachycardia

and fever despite normal WCC and CRP IV immunoglobulin and plasma exchange no

effect 50% association ovarian teratoma, US showed

no evidence of this…ovaries taken out and found to have microscopic evidence of teratoma

Slow but steady clinical improvement following this.

CASE 2 36 yo 5/7 insidious onset generalised

headache No recorded temperatures but getting

hot/chills at home Vomited at home No photophobia, no meningism, petechial

rash Recent fishing trip-lack of sleep, alcohol++ Nil significant PMH GCS 15/15 looks well from the end of the

bed. Normal CRP, normal WCC

CASE 2 Appearance: turbid Cell Count

Leucocytes 2580 /uLPolymorphs 20%Lymphocytes 80%Erythrocytes 24 /Ul

BiochemistryProtein 0.99 g/LGlucose 2.8 mmol/L (2.8-4.4)

Microscopy No bacteria seen Culture no growth

CSF PCR Enterovirus/ Rhinovirus RNA not

detected Herpes Simplex virus 1 not

detected Herpes Simplex virus 2 not

detected Neisseria meningitidis not

detected Varicella Zoster detected Streptococcus pneumoniae not detected

CASE 3

CASE 3

CASE 4

BACTERIAL MENINGITIS Ideally blood cultures and CSF prior to IVAB Should not delay the commencement IVAB

>30minutes Dexamethasone 10mg IV before or with first dose

of IVABPLUS Ceftriaxone 4g or cefotaxime 2gAdd Benzylpenicillin is suspect Listeria

(immunocompromised, >50yrs, alcoholic, pregnant)

Vancomycin is suspect pneumococcus (gram +ve diplococci, otitis media, sinusitis, treated beta lactam)