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  • So does she still needthe steroids?

    Wednesday ID Case Conference

    Christopher Hurt, MDApril 4, 2007

  • 7/18/07 2

    HPIHPI

    NL is a 56yo Latina transferred for SAH

    Presented with N/V, dizziness and blurry vision

    Initially in outside ED was OK but rapidly becameobtunded; ETT for airway protection

    Head CT showed fresh blood, sent to UNC forNSG eval

    Addl imaging at UNC showed extensive bleedinto basal cistern, bilateral Sylvian fissues, andalso IVH with pooling in temporal horns

  • 7/18/07 3

    HPI, contHPI, contdd

    Taken to angio suite for eval of possible aneurysmfor intervention

    Fusiform aneurysm of L vertebral artery identified

    No coiling done

    Started on phenytoin and nimodipine, EVD placed

    MRI/MRA obtained to look for other aneurysms

    No recent constitutional symptoms had been inUSOH up until this time

  • 7/18/07 4

    PMHxPMHx//PSHxPSHx

    HTN

    T2DM, as a new diagnosis on admission to UNC

    No prior surgical history

  • 7/18/07 5

    SocHxSocHx

    Originally from Mexico; undocumented

    Lives in Mount Olive, NC with extended family

    Works as housekeeper

    Unknown pet/animal exposures

    Unknown environmental exposures

    Unknown exposures to children

    Sexual history unknown

    No recent travel outside NC

  • 7/18/07 6

    FHxFHx

    UTO

    Meds, AllergiesMeds, Allergies No o/p meds Hospital meds:

    Amlodipine Atorvastatin Docusate Famotidine Nimodipine Phenytoin Propofol Labetalol PRN RISS

  • 7/18/07 7

    PExPEx

    Gen: Intubated, sedated,unarousable to voice

    HEENT: NCAT. EVD present.Anicteric, noninjected OU.

    Neck: UTA given ETTChest: CTAB anterolaterally,

    coarse overallCV: RRR, no m/r/g. S1/S2.

    Abd: Soft, NTND. NABS.Ext: Warm/dry, no c/c/e x4.Skin: No petechiae, rashes,

    ecchymoses. No stigmataof IE peripherally.

    Neuro: PERRL. Gag intact.UTA other neuro findingsgiven sedation.

    Tm 38.6 HR 110 BP 139/75 RR 19 96%40Fi, vent

  • 7/18/07 8

    LabsLabs

    11.6

    3417 182

    145

    3.4

    116

    21

    7

    0.5113

    AST, ALT normalA 150 - GGT 103

    PBCx pendingUCx pendingCSF from EVD pending

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    More pretty picturesMore pretty pictureswere obtainedwere obtained

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    Inflammatory aneurysmInflammatory aneurysmfrom from neurocysticercosisneurocysticercosis

  • 7/18/07 17

    Hospital CourseHospital Course Serum neurocysticercosis WB sent; was negative Primed with dexamethasone in advance of

    empiric antihelminthic therapy Neuro status tenuous, per NSG team Attempts at clamping EVD with limited success Taken to angio suite and had L vertebral artery

    sacrificed with coiling Treatment with albendazole deferred by ID team,

    given potential for catastrophic outcome(s) NSG pressed for treating, but never did Now convalescing on PM&R service, doing well

  • 7/18/07 18

    Taenia soliumTaenia solium Humans both int, definitive host Pigs eat vegetation

    contaminated w/eggs or gravidproglottids

    Oncospheres hatch in bowel,invade wall, migrate to striatedmuscle or brain, encyst

    Cysticerci ingested inundercooked, infected pork

    Adult tapeworms in human gut

    http://www.dpd.cdc.gov/DPDx/HTML/Taeniasis.htm

  • 7/18/07 19

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    NeurocysticerciNeurocysticerci Made up of scolex and

    vesicular wall Viable cysts measure ~10mm Tend to lodge in basal ganglia,

    cortex bc of vascular supply Subarachnoid cysts lodge in

    cortical sulci or in cisterns After long period, scolices lost

    and dia grows, up to 50mm(esp. cisternal/subarachnoid)

    Racemose form = grapelike

    Nonviable cyst(dead scolex;

    viscous, turbid fluid)

    Sotelo J, et al. Neurosurg Focus 2002;12(6):1-7

  • 7/18/07 21

    Aneurysms from NCC?Aneurysms from NCC? Case-reports Presumed from inflammatory exudate coalescing

    around vessels in dependent portions of skull Entrapment of vessel in debris / material Vascular wall weakness, dilatation then, POP!

    Outcomes good in reported cases

    Soto-Hernandez J, et al. Neurosurgery 1996;38(1):197-200Huang P, et al. Neurosurgery 2000;47(2):466-468

  • 7/18/07 22

    Treatment of Treatment of subarachnoid subarachnoid NCCNCC 36 patients with subarachnoid NCC randomly to

    dexamethasone 8mg iv q8h for 4d, plusalbendazole on day 5: 15mg/kg/d for 8d 30mg/kg/d for 8d

    Marked clinical improvement on just steroids Larger cyst reduction on MRI at 90, 180d at

    higher-dosing Single-course insufficient to treat intraventricular

    or giant cysts Steroids x3 to 6 mos after albendazole

    Gongora-Rivera F, et al. Neurology 2006;66(3):436-438

  • 7/18/07 23