Friday 23 December 2016

60F with Coma, E Coli sepsis and upper motor neuron signs with albumino cytological dissociation in CSF.

Title:- 60F with Coma, E Coli sepsis and upper motor neuron signs with albumino cytological dissociation in CSF.


Disclaimer:-

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

18 years ago my mother in law had been admitted to hospital for problem in Neck. She was having feeling like current in hand, legs and nausea, vomiting, vertigo, and got admitted at hospital. She was recommended surgery and doctor said there may be huge complications because of surgery. Since it was dangerous we had opted for no surgery and try to manage on medicine only. She was advised a medicine called Baclofen when needed. She was taking it 2-3 times a week, since then but recently 4 months ago she started taking that medicine daily.

She never gad Diabetes, Never had Hypertension, Non-veg diet (white meat), no smoker in family, used to cook on chulha till 20 years ago, our home was in area of coal mines but 18 years ago we had shifted to urban area.

4 months ago she started more neck pain, electric current like feeling in whole body, headache, body pain, nausea, vertigo, vomiting, fever (random) breathlessness and loss of sensation in little finger and ring finger and so she had even started taking baclofen twice a day. She was unable to stand/walk we had to admit her in hospital, and got suggestion for problem in spine, referred to another hospital for surgery, to cut bone, Then before surgery they said of low blood cells, and also next day, blood cells were low so surgery was cancelled and she was referred back till blood cells become normal, and same time also found ulcer due to infection in stomach. Then we took her to another hospital after 7 days and she was admitted to ICU and before admitting we also found that she had got bed sores on back. They did many test and gave her blood after 2 days and albumin. She became better, Then we took her home and she was still having tube in her mouth to give her food. We gave her food by tube for 5 days, and packet juice using same tube and feeding injection, a person used to come and do dressing for her bed sores which had improved, but on around 8th day she got diarrhoea, 4-5 times 1st day and it became fine after 3 days without giving any medicine for diarrhea. She was only on already prescribed medication. Her stool was water like, no blood and and blackish so we stopped giving her pomegranate juice.

After staying 15 days at home, her breathlessness worsened , nausea, vertigo, vomiting, weakness, pain in chest and back started. Blood report was 5.6 haemoglobin and after 10 days on doctors advice we gave her 2 unit blood but her hemoglobin came only to 5.7 and so next day 1 unit blood was given then 10 days ago she started having severe breathlessness, unconscious, have been given lots of blood daily. and have infection in blood.





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- Sepsis (MDR E. Coli)
- Cervical Myopathy
- Pancytopenia
- Ascites
- Anaemia
- Splenomegaly (stony)
- Encephalopathy
- H. Pylori +ve Ulcers
- Vit. D deficiency
- Altered sensorium
- Unconscious - non responsive
- Bed Sores - Sacral region & 2nd degree
- BP 159/70
- RR 33 (on ventilator, 16 by self)
- Temp. 95F
- Blood transfusion
- Pallor ++
- edema +
- Soft Hepatomegaly
- Hypokalemia
- Had rectal bleeding (fistula)
- Blackish stools






















































Comments
Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Kaushik Sundar, Praveen Ky any inputs on the albumino cytological dissociation in CSF of this patient of myelopathy?

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मोनिका पठानिया राठौर We have to look for cause of paralysis - drugs, virus, autoimmune

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Madhumita Sen Cervical myelopathy. But why stony hard splenomegaly and pancytopenia? Malignancy? Drug induced?

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Michele Meltzer "From the history it sounds like cevical myelopathy. I would check to see if any meds, including antibiotics she took could have caused pancytopenia. You might show photo of her hand looking for muscle atrophy or contracture

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Avinash Kumar sadly she left. She didn't had muscle atrophy in hands as far as i remember. anything you found?
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Kaushik Sundar My take on this case
"18 years ago my mother in law had been admitted to hospital for problem in Neck. She was having feeling like current in hand, legs and nausea, vomiting, vertigo, and got admitted at hospital. She was recommended surgery and doctor said there may be huge complications because of surgery. Since it was dangerous we had opted for no surgery and try to manage on medicine only. She was advised a medicine called Baclofen when needed. She was taking it 2-3 times a week, since then but recently 4 months ago she started taking that medicine daily."

1. Patient was having neck pain- 18 years ago, with spasticity (hence the baclofen). Was advised surgery, but refused to undergo the same.- Probably cervical myelopathy
2. Nausea, vomiting, vertigo are not symptoms of Cervical myelopathy. For the info of junior doctors here- vertigo can occur in cervical spondylosis only if the vertebral artery canal is stenosed. These symptoms can be explained by a lesion in the medulla- hence the possibility of CV junction anomaly
3. Patient was able to pull along till almost 17 years, and only needed to increase the dose/frequency of baclofen for the last 4 months- So whatever the lesion was it was probably static or very very slow in terms of progression- ?Degenerative/?Tumors that are probably benign that dont increase in size.
4. Very difficult to say if it is extra dural or intra dural, but intra medullary lesion is probably not on the cards as there is no early bladder involvement.
5. There is no respiratory muscle involvement till now.

4 months ago she started more neck pain, electric current like feeling in whole body, headache, body pain, nausea, vertigo, vomiting, fever (random) breathlessness and loss of sensation in little finger and ring finger and so she had even started taking baclofen twice a day. She was unable to stand/walk we had to admit her in hospital, and got suggestion for problem in spine, referred to another hospital for surgery, to cut bone,

1. Her old symptoms have revisited her.
2. Loss of sensations in the little finger and ring finger- Could tell us a clue regarding the localization to lower cervical region- However false localizing signs to lower cervical region by a upper cervical lesion is known to occur- secondary to venous congestion and other such theories- I take this history, with the probability that it is a false localizing sign.
3. Breathing difficulty- is it a part of the higher cervical lesion?
4. Surgery is advised again.
Why the fever?

Then before surgery they said of low blood cells, and also next day, blood cells were low so surgery was cancelled and she was referred back till blood cells become normal, and same time also found ulcer due to infection in stomach. Then we took her to another hospital after 7 days and she was admitted to ICU and before admitting we also found that she had got bed sores on back.

1. Patient had fever and low cell count- Could be a part of generalized sepsis.
2. Ulcer in the stomach- could it be stress ulcers?
3. Bedsores- Patient is now moribund, non ambulatory and does not turn from one side to another, with reduced sensations over the back- a worsening of her neurological status
What was her ambulatory status at home? was she walking around? could she go to nearby shops, climb stairs etc.,. sometime caregivers dont mention her functional status very clearly.

They did many test and gave her blood after 2 days and albumin. She became better, Then we took her home and she was still having tube in her mouth to give her food. We gave her food by tube for 5 days, and packet juice using same tube and feeding injection, a person used to come and do dressing for her bed sores which had improved, but on around 8th day she got diarrhoea, 4-5 times 1st day and it became fine after 3 days without giving any medicine for diarrhea. She was only on already prescribed medication. Her stool was water like, no blood and and blackish so we stopped giving her pomegranate juice.

1. She was on ryles tube- did she have a palatal weakness? 
2. She was better- Does that refer to the sensorium

After staying 15 days at home, her breathlessness worsened , nausea, vertigo, vomiting, weakness, pain in chest and back started. Blood report was 5.6 haemoglobin and after 10 days on doctors advice we gave her 2 unit blood but her hemoglobin came only to 5.7 and so next day 1 unit blood was given then 10 days ago she started having severe breathlessness, unconscious, have been given lots of blood daily. and have infection in blood.

1. Neurological symptoms continue to worsen, despite interim mild improvement.
2. Hb dropped to 5.6 ( with a history of blackish stools)- is melena still persisting?
3. Became breathles and unconscious- With evidence of sepsis.

will update my views on the reports in just a bit, got a train to catch- Going home for christmas 

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Kaushik Sundar The temperatures have been normal to hypothermia- was the patient in a state of shock?1. Even for sepsis, it's usually warm extremities. 2. Can myelopathy explain hypothermia? Well if there is severe autonomic dysfunction that can occur in myelopathies(less likely)Manage

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Kaushik Sundar I would have liked to see the patients older abg, however the serial abgs show fall in ph with increasing Pco2 retention with normal bicarbonate levels- type 2 resp failure with resp acidosis- why does she have a Pco2 build up- resp muscle failure? Fall in sensorium? Abg not very suggestive of a septic/metabolic acidosis picture- even lactates are not too badManage

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Michele Meltzer I am sorry, I missed the hard spleen. Then cervical myelopathy and cancet

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Kaushik Sundar These investigations show pancytopenia- but differential count shows pmn predominance. Rft electrolytes are relatively ok. Would have liked to see the lft though. The anemia is also normocytic. What is the ps like.

An interesting read for approCh to pancytopenia 
https://www.karger.com/Article/ShowPic/69577/...Manage

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Amit Taneja 1. Cervical myelopathy
2. Probable hematologic malignancy or myeloproliferative disorder 
3. MDR E. coli sepsis 
4. Developing respiratory failure from diaphragmatic fatigue, CNS depression etc
5. Albuminocytologic dissociation is either a red herring or a manifestation of carcinomatous meningitis

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Amit Taneja A bone marrow bx and repeat LP for cytology may be helpful
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Thanks Amit, Bone marrow biopsy showed erythroid hyperplasia
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Praveen Ky Two ways of approaching this case 
1.Dissociating the cervical myelopathy from the systemic illness and superadded sepsis. 
I wud like to known the mri cervical spine findings -if it's a degerative myelopathy we can straightaway separate it from the medical illness.If it shows some sort of compression due to tuberculosis/deposits or infiltration it can well be associated with the systemic illness.If MRI is showing intramedullary diseases like demyelination or intrinsic cord involvement then we can again beach explained along with the hematological malignancy/paraneoplastic process...

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Praveen Ky Again the altered sensorium has to be evaluated seriously. Whether it is a part of toxic encephalopathy or whether their is meningoencephalitis.....raised protein in csf /ada positivity may be related to that. Carcinomatous meningitis cud be a positivity secondary to hematological malignancy. ....MRI or CT brain with contrast would give us the clue...

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Praveen Ky Coming to the systemic issues --
She is having pancytopenia --whether it is a secondary to the a hematological malignancy is crucial.Bone marrow biopsy/peripheral smear is crucial. 
The liver echo texture ---whether any evidence of cirrhosis as it may explain spleniomegaly and pancytopenia.hepatic myelopathy may coexist.varices are absent is odd.LFT pattern may give a clue regarding the cld. ...

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Praveen Ky Sepsis as can occur in any pancytopenic pt is well explainable
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Praveen Ky Immune mediated disorders like SLE/Sjogrens .....etc has to be ruled out which can explain the hematological findings as well as noncompressive myelopathy. ...though lower in the list
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Praveen Ky Regarding csf protein increase in myelopathy with n cells --'the causes are ---
1. Demyelinating spine disease like NMO/ADEM/ MS
2.Vasculitis involving spine
3.paraneoplastic myelopathy
4.loculation syndromes due to spinal obstruction 
5.diabetic pt with renal dysfunction

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Kaushik Sundar Csf findings showing high protein, normal sugar and normal cells- this pattern could be seen in a lot of settings including- septic encephalopathy, aseptic meningitis, immunocompromised state, demyelination etc.,. My doubt would be, If the patient already has a pancytopenia,wouldn't the csf cell count be falsely low? However would like to keep septic encephalopathy as a possibility

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Praveen Ky That's true ....cells may be falsely low...

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Praveen Ky I think ....cervical spine mri images if available ...would be very useful to determine the etiology of myelopathy. ...
tuberculosis cud be high in the list....csf ada is high...myelopathy can be well explained with it....It can occur in a disseminated manner in pancytopenic patient....and even pancytopenia and organomegsly may be direct manifestation of tuberculosis. .

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Boudhayan Dm What to do and how to approach when u do not have MRI facility at your centre and you are not in a position to transport her to another centre for the same. How do we treat? Antibiotics for Sepsis....... How can we treat the cause? Is splenic biopsy a viable option in such a moribund patient
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Boudhayan Dm Kaushik Sundar Koushik Dutta Praveen Ky What is the relation between peripheral count and CSF count in such a scenario? Even if CSF count was increased what was the possible Rx which could have been offered?
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Praveen Ky CT Brain with CT cervical spine.....With contrast may be planned.Bone marrow biopsy.TB PCR In CSF.
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. CT brain was normal. Cervical MRI done in Vivekananda (Avinash i think they have the MRI films, do you have their number?) was near normal. Bone marrow showed erythroid hyperplasia
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Boudhayan Dm CT as far as I remember did not yield any useful information...... Bone Marrow study if I am right yielded no results either
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Praveen Ky This patient if having a meningitis has probably tuberculous/fungal or carcinomatous meningitis
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Thanks but in the absence of cells (just 5) can we call it a meningitis?
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Praveen Ky Sir...In view of pancytopenia and immunosuppresed status....TBmeningitis and carcinomatous meningitis still remain a possibilty

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Praveen Ky It cannot be ruled out

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Boudhayan Dm In such cases when history is not good enough to reach the definite diagnosis and investigations also have their limitations...... What should be the treatment approach?Do we use a cocktail and see for favourable results...... I guess the ideal scenario is the best...... But when it is not how best should we approach the Rx........ Kaushik Sundar Praveen Ky

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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. This patient had a massive enlarged spleen (Avinash you needed to add the image of our notes with the diagram of her spleen).  In the presence of pancytopenia and erythroid hyperplasia and low serum albumin as well as deranged prothrombin time our first suspicion was toward portal hypertension and liver failure causing hepatic encephalopathy

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Praveen Ky Yes sir....I had mentioned it before....The odd point was no varices. ....The liver echo texture in ultrasound? ??...

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Praveen Ky Was serum ammonia done?
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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Can we send serum ammonia to any place in Durgapur?
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Praveen Ky EEG ....may be planned which may show slowing and triphasic waves cud be supportive for hepatic related encephalopathy

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Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Liver echotexture was unremarkable (or perhaps not remarked on)
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Praveen Ky It's done at mission .....lalpath lab...arterial ammonia
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Boudhayan Dm Well we wanted to send Serum ammonia but anyways we had encephalopathy.....can we discuss the usefulness of serum ammonia- a lot of controversy exists. Yes EEG was another inv we did not utilise or rather could not utilize. Would availability of Serum Ammonia made any difference to the treatment options we exercised. Rx options for hepatic encephalopathy was exercised. My qs again........Is splenic biopsy in such a scenario feasible or possible in our set up in the present scenario Rakesh Biswas Praveen Ky Kaushik Sundar
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Praveen Ky Hepatic precoma regimen .....could have been tried....
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Boudhayan Dm It was given in an empirical manner
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Boudhayan Dm What are the causes in our present patient Praveen Ky which could have caused a false elevation of Serum Ammonia? Arka De Harsh Tevethiahow relevant is Serum Ammonia in this scenario when coverage for hepatic precoma is already given?
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Praveen Ky Sepsis ....drugs etc may increase the nh3. ...well treatment wise it wouldnt have made a difference
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Praveen Ky But then liver would gain the focus here....hematological malignancy /tb /fungal inf wud go lower down in the differentials

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Praveen Ky We wud be looking for causes of liver failure ....like hepatotrophic viruses.....Wilsons. ....autoimmune hepatitis etc wud come in the d/d
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Boudhayan Dm Can hyperreflexia be explained by hepatic encephalopathy? We covered for Sepsis, Hepatic encephalopathy and all possible supportive etiology...... Hepatic virus screen was negative..... How common is a moderate hard splenomegaly in Wilson s ? For diag...See more
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Boudhayan Dm Dipendu Mazumder Debdatta BasuJayanta Roy Abhijit Das would request your inputs on the management of this patient.
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Boudhayan Dm What we have not discussed is Baclofen and CNS side effects Jayanta Roy Abhijit Das Kaushik SundarPraveen Ky Ananya Chakraborty Rovin Vincent Ayon Bhattacharya

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Avinash Kumar Rakesh Biswas Boudhayan Dm Vivek Poddaryour views sir?

An article strongly suggesting possibile treatment in sepsis case by vitamin C but lack evidences to proove.

http://www.npr.org/.../doctor-turns-up-possible-treatment...Manage

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Avinash Kumar Got it sir, Vitamin C Megadosage by Linus Pauling https://en.m.wikipedia.org/wiki/Vitamin_C_megadosageManage

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