Cool case

[neglect]

65 yo with advanced leukemia is admitted to oncology with a fever (which several notes called FUO). This has been associated with 'confusion' per his wife, consisting of the inability to carry his end of conversations. Neuro is called because he's acting funny on hospital day number 2.

Sorry to frusterate you, I'll give the exam later, but what are your thoughts, what should be done, and will you take this patient on your service?

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[kasimagore1]

There are many things for AMS. Other than metabolic causes, I was wondering about chronic meningitis from mets. The hx you provided is incomplete, and without a neuro exam, it could be many things. Futher w/u would probably start with a MRI with Gad +/- LP. I thnk this patient is probably best served by medicine or heme/onc service. Neurology consult and close f/u should be sufficient for now.

65 yo with advanced leukemia is admitted to oncology with a fever (which several notes called FUO). This has been associated with 'confusion' per his wife, consisting of the inability to carry his end of conversations. Neuro is called because he's acting funny on hospital day number 2.

Sorry to frusterate you, I'll give the exam later, but what are your thoughts, what should be done, and will you take this patient on your service?

 

[omores]

Ooooo, fun.

My thoughts:

This could be a direct result of his leukemia (i.e., CNS involvment). He could also be battling an infectious process because of immunosuppression (from the leukemia or from chemo). Or it could be iatrogenic: the direct effect of a med he's been taking, or an indirect effect of his treatment (e.g. messed up lytes, etc.)

Work-up: imaging (CT or MRI depending on how weird he's acting), standard labs, and history history history (including detailed history of how his leukemia is being managed). Neuro exam would be nice, too! Oh yes, and LP, please.

Keep him on the onc service for now , but watch him closely -- "will follow with you" on the consult note.

 

[neglect]

OK, was kidding about the change of service thing.

Clearly you're hitting the wide ddx, which is good.

You have to be thinking that an immunocomp. pt. with confusion needs to go down the meningitis/encephalitis pathway. The way to do this, btw, is to shoot first and sort it all out later: start abx to cover ALL bacteria in the meninges and probably acyclovir in the unlikely chance that its HSV. You could even make a case for fungal. Then get the CT and LP (his plts are ok, don't tap anyone with plts less than 50, even though heme might say this is OK). Then stop abx/anti-virals as needed.

However, that's premature. When you see him his exam shows:

Fever
MS: alert. Makes good eye contact. Cannot follow two step commands. Cannot repeat. Answers questions with yes, no. Makes little spontaneous speech.

The remainder of the exam shows a right field cut and a subtle right facial with right drift. Reflexes are down all over.

The oncology people said he had a normal head CT with and without on admission and he hasn't changed since then.

Now what?

 

[kasimagore1]

Okay, so it probably localizes to a left cortical region given its involvements of language, vision and even some paresis. Does the patient answer yes or no questions correctly or in a random fashion? This patient appears to be a little bit abulic--does his exam fit in with akinetic-abulic syndrome or even akinetic mutism? If so, there may be some frontal lobe involvement? Does patient have conduction aphasia? Also, does the patient really seem confused or did he have an impairment in comprehension (or just decreasd concentration due to systemic illness? )

Okay, so what does labs show? Is it safe to tap this guy? If so, what does CSF show? What are you going to send for CSF? besies the usual chem, cx, I probably would send for HSV, VZV PCR, VDRL, ANA, ? ACE, ? EBV, AFB culture.

The anticipation is killing me, it's like taking step 3 with all the clinical scenarios.

 

[neglect]

Okay, so it probably localizes to a left cortical region given its involvements of language, vision and even some paresis.

Correct. Why waste time with any further questions on the exam? Do we really care? His exam shows everything referable to left hemisphere, and there's little to no confusion as initially picked up by onc. This makes him focal.

Labs show that he has leukemia. He's safe to tap, but there's another consideration in this febrile cancer patient before you do so.

 

[neglect]

Any guesses before I give it to you? Cancer guy, infected, and focal.

What if his repeat head CT shows a wedge shape hypodensity in the left MCA territory?

 

[neglect]

The guy had endocarditis.

Initial blood cultures were neg because it was partially treated. As soon as we identified the fact that he was focal, we told the primary team that this could be stroke, could be from heart, could be infective/non-infective endocarditis. They put him on appropriate meds and later a TEE showed a floppy thing on a valve.

Anyway, thought this was a cool case because we seldom think of stroke as infective. Plus we drastically changed mgmt.

Anybody have any more, or was this not fun?

 

[omores]

Yes, it was fun! Sorry, I'm on an interview junket right now and have not been able to keep up with this thread. But at least now I have some closure.