A CASE OF ALTERED SENSORIUM

CLINICAL CLUB
• 79 year old female

Admitted on 22/04/2022
Chief complaints:

Fever - 17 days
Altered sensorium – 17 days
Involuntary movements – 16 days
Loss of consciousness – 15 days
• Developed an insidious onset, low grade,
continuous fever without chills or rigor,
subsiding with medication.
• Fever persisting through course of illness,
being present on most of the days
• One episode of vomiting without nausea,
containing food particles
• On the same day the fever developed, son
noticed a difference in personality of the
patient.
• Daily routine affected – skipping morning
exercise, staring look, changed food
preference
• Speaking incoherently and at times engaging
in conversations with herself
• Taken to nearby hospital, next day developed
involuntary tapping of right hand on bed with
right knee movement.
• Event lasted for about 15 minutes, patient
being conscious throughout the event.
• Lip smacking + during and after the event.
• While being transported here, sensorium
worsened, patient responding to calls and taps
with moans.
• Developed loss of consciousness as she
reached our casualty, lasted for a few minutes
after which she was unresponsive but kept her
eyes open.
• Patient on admission kept in ICU on ventilator
support, preferably moved right side of body
and persistenly looked towards left side.
• At present patient is in ward, moves right side
of body preferably.
 Past history
• No history of comorbidities like DM, HTN, DLP,
old PTB, CAD
• H/o COVID-19 infection, Category B in March
• Lumbar spondylosis – 30 years not on regular
medication
 Personal history
• Consumes non- vegetarian diet.
• Increased sleep- daytime sleepiness, more
towards the evening hours +
• Patient after disease onset passes stools only
once in 3-4 days
• No history of addictions
 Menstrual history
• Menarche at the age of 38
• History of regular cycles with hypomenorrhea
• Hirsutism +
• Mother of 4 – normal vaginal delivery
 Family history
• No significant history of illness in the family
• Mother of 4 – 2 males and 2 females
 General Examination
• E4V2M6
• Patient moving all four limbs
• No pallor/icterus/cyanosis/clubbing/
lymphadenopathy/edema
• Hyper pigmentation of palms +
• Hirsutism +
• No rashes or vesicles noted over the body
 Vitals
• Pulse -rate : 86/’, regular, normal volume and
character, no radiofemoral delay, all peripheral
pulsations checked present bilaterally equal

• BP : 100/60 mm Hg
• Temperature: 99F
• Respiratory rate : 21/’
 NERVOUS SYSTEM EXAMINATION
Higher mental function :
• E4V2M6
• Patient is drowsy but arousable
• Glabellar tap +
• Pout reflex +
 CRANIAL NERVE EXAMINATION
• CN I : Could not be tested
• CN II : PEARL, b/l Pseudophakia
• CN III,IV,VI : Left gaze preference +, Direct and
indirect light reflex +
• CN VII : WNL
• CN IX, X : WNL
Motor system
• Normal bulk and tone
• Paucity of movements of UL > LL
• Reflexes
RIGHT LEFT
BICEPS JERK + +
TRICEPS JERK + +
SUPINATOR JERK + +
KNEE JERK - -
ANKLE JERK - -

• Bilateral flexor plantar +

• Sensory system and cerebellar signs could not
be tested/elicited

• Neck stiffness +
• Kernig’s sign and Brudzinski sign -
 Other systems
Respiratory system :
• Air entry heard bilaterally equal
• Crackles heard over right infra axillary and infra
scapular area and left infra scapular area

Cardiovascular system:
• S1 S2 +, No murmur
Gastrointestinal system :
• Soft, no hepatosplenomegaly, bowel sounds +
 Provisional diagnosis
• Non convulsive status epilepticus
• Acute meningoencephalitis
• ? HSVencephalitis
• ? Aspiration pneumonia
INVESTIGATONS
 22/04/22 24/04/22 26/04/22 01/05/22 04/05/22

Hb 12.1 10.3 9.3 9.4 9.1

Platelets 1.71 1.67 1.45 2.49 2.39
Total Count 16.0 17.4 10.5 9.55
DC 84.7/8.0/0.0 89.2/7.7/0.1 78.5/15.6/1.7 72.8/20.7/3.8 77.2/16.4/4
ESR 26 134 55
RFT 23/0.7 42/0.8 28/0.7 24/0.7 24/0.7
Total/Direct 0.7/0.1
bilirubin
SGOT/SGPT 46/35
ALP 64
Total proteins 7.3
S. Albumin 4.1
S. Globulin 3.2
Na+/K+ 124/2.9 123/2.7 125/3.9 131/3.6 128/4.1
INR 1.00
PERIPHERAL SMEAR
 CSF STUDY (23/04/22)
• Protein – 42 (12 - 60)
• Sugar – 75 (40 -70) [Blood sugar 184]
• WBC – 20
• RBC – 9
• ADA – 1.74
• Neutrophils – 1/20
• Lymphocytes – 19/20
• Gram stain and culture - Normal
MRI STROKE SCREENING
EEG (23/04/22)
HSV DNA (25/04/22)
 DIAGNOSIS
• HSV – 1 ENCEPHALITIS
 HSV ENCEPHALITIS
• HSV-1 strains cause over 90% of cases of
herpes simplex encephalitis (HSE) in adults,
with the remainder due to HSV-2.
• Conversely, HSV-2 is a more common cause of
meningitis and neonatal meningoencephalitis
than HSV-1.
• Both HSV types 1 and 2 have been associated
with myelitis.
• Fever is present in about 90% and headache in
about 80% of patients with biopsy or PCR
proven HSE.
• Disorientationtion (70%), personality change
(70%–85%), focal or generalized seizures
(40%–67%), memory disturbance (25%–45%),
motor deficit (30%–40%), and aphasia (33%)
• No sets of signs or symptoms are
pathognomonic of HSE
• CSF is usually under increased pressure, with a
lymphocytic pleocytosis of 10 to 1,000 white
blood cells (WBC) per μL. Over 95% of PCR or
biopsy-proven cases of HSE have a CSF
pleocytosis
• The presence of red cells in CSF may be
associated with a worse prognosis
• CSF protein is usually moderately elevated and
glucose is normal in more than 90% of
patients with HSE.
• Surprisingly, the HSV viral load is not a predictor
of outcome
• Approximately 90% of patients with PCR-proven
HSE will have MRI abnormalities involving the
temporal lobes
• EEG may be abnormal early in the course of
disease, demonstrating diffuse slowing, focal
abnormalities in the temporal regions, or periodic
lateralizing epileptiform discharges (PLEDs).
• EEG abnormalities involving the temporal lobes
seen in approximately 75% of patients with PCR-
proven HSE
• Empirical therapy with ACV should be started
immediately in acute cases of focal
encephalitis of suspected viral etiology

• Mortality in untreated cases of HSE is around

70%, but this is reduced to 19% to 28% in
patients treated with ACV
• Morbidity due to HSV-1 encephalitis remains
high even in patients receiving ACV, with only
37.5% of all patients surviving with no or only
mild deficits
• Survival and prognosis are influenced by
several factors including level of consciousness
at initiation of therapy (e.g., GCS), patient age,
and duration of disease before therapy
• In the CASG trial, all (9/9) patients treated with ACV
within 4 days of onset of fever, headache, and focal
neurological deficits survived, whereas the mortality
was 35% in those in whom ACV treatment was
initiated when disease was more than 4 days old
• In another study, the recovery rate was 50% in
patients treated within 5 days of illness onset.
• In a third study of PCR-proven HSE, 75% of patients
with an ultimately favourble outcome had received
ACV therapy within 2 days of hospital admission
compared to only 30% of those with a poor outcome
• The standard adult dose of acyclovir for HSE is 10
mg/kg, given intravenously (IV) every 8 hours (20
mg/kg every 8 hours in neonates and children) for
14 to 21 days.
• Oral valacyclovir may be an alternative when
intravenous acyclovir is unavailable
• Retrospective studies have sug- gested that there
may be some benefit in adding corticosteroids to
ACV treatment
• Foscarnet is an alternative therapy for patients
with suspected or proven ACV-resistant strains or
with allergy to ACV