UCI MICU Case
Presentation
HPI
CC: HA, fever, weakness, and nausea x 2 days
HPI: 58 y/o M who presented to UCI ED
- 8/3: pt. developed headache w/ photophobia and
phonophobia that resolved with Tylenol
- 8/4: Patient received HD which was followed by nausea,
restlessness and fatigue and he then became agitated &
restless
- 8/5: Presented to UCI’s ED
PMHx
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ESRD 2/2 diabetic nephropathy with LUE AVF, HD MWF
Anemia 2/2 ESRD
IDDM
Uncontrolled HTN
Diastolic HF with EF 63% (3/5/14)
Pancytopenia
• Surgeries
• LUE AVF 2010
• Amputations= R 2nd toe (2011), L 1st toe (1995)
Meds/Allergies/FHx/SHx
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Renelva 1600 mg TID
Phoslo 667 mg 2 tablets TID
Metoprolol 100 mg BID
Clonidine 0.1 mg TID
Amlodipine 5 mg 4 times per wk on non-HD days
Ranitidine 150 mg qday
Tradjenta 5 mg qday
Lantus 14 u qday
• Allergies: NKDA
• FHx: h/o DM2 in both sides of family. No renal issues or cancers.
• SHx
• No EtOH, smoking, IV drugs
• lives at home in Santa Ana with family and is retired
ED Course
• VS: T 102.5, P 85, BP 183/90 R 16 O2 98on RA
• Gen: sick, vomiting x1 during interview, altered, AOx2, states year is
1940
• HEENT: nc/at, anicteric sclera, MMM, EOMI, PERRL
• Cardio: RRR, +S1, S2, no m/r/g, no JVD, no carotid bruits. Palpable
thrill in R radial artery from AVF.
• Pulm: CTAB, no w/r/r, normal work of breathing
• GI: +BS, soft, nt/nd, no hepatosplenomegaly
• Skin: no c/c/e
• Neuro: face symmetric, equivocal sensation in cranial V1,2,3
distribution, 5/5 facial strength, tongue midline, puffs cheeks,
smiles. Intention tremor present on finger to nose test. No
pronator drift.
• Musc: 5/5 muscle strength in all major muscle groups of BUE and
BLE.
Labs
Labs cont’d
CXR
ED Course
• CT Head:
• No evidence of acute intracranial hemorrhage, mass effect or
hydrocephalus
• LP was attempted and aborted 2/2 agitation
• Patient admitted to family medicine
Hosp Course
• 8/5:
• Started on Vanc/Zosyn for possible pneumonia
• LP planned for next day
• Plans for MRI
• 8/6:
• Patient with worsening rigors, fevers and AMS
• Primary team concerned for meningitis vs endocarditis vs pulm
embolism
• Patient transferred to MICU and abx coverage changed to
• Vanc, Cefepime, Ampicillin, Acyclovir
• LP performed
CSF Results
Labs/Cultures:
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HIV: negative
Coccidioides IgG/IgM: negative
Crypo antigen: negative
Mycoplasma IgG/IgM: negative
Histoplasma: negative
Pregnancy test: Negtaive
Cultures
• Sputum (8/7): NGTD
• Bld cx (8/4): NGTD
• Repeat bld cx (8/6)-AVF: NGTD
CSF Cultures
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Enterovirus: negative
Viral culture: no virus isolated
VZV: negative
Bacterial culture: NGTD
Fungal culture: negative
Acid fast bacillus (TB): negative
Cryptococcus: negative
HSV1/2: negative
Hosp Course
• 8/6: Tonic clonic seizure like activity observed
• Loaded with Keppra
• EEG: Moderate degree of generalized cerebral dysfunction with
no epileptiform abnormalities
4 days later
Diagnosis…
West Nile Meningoencephalitis
West Nile Virus
• Symptoms develop in 30-40% of those infected
• Life long immunity
• Incubation period: 2-14 days
• Longer among immunosuppressed patients
• Common presentation: low grade fever, headache, malaise,
back pain for 3-6 days before presentation
• Can present as meningitis vs encephalitis vs acute flaccid
paralysis
• 25-50% of patients develop a rash
• Can lead to acute flaccid paralysis
West Nile Virus
• Diagnosis:
• IgG + IgM CSF and serum
• Plasma West Nile virus RNA
• CSF:
• Pleocytosis with lymphocytic predominance
• Increased protein
• Normal glucose
• CT head usually reveals no acute findings
• MRI shows increased sign intensity in brain stem
• EEG shows generalized, continuous slowing
West Nile Virus
• Treatment:
• Supportive measures
• IVIG: Been suggested as possible therapy; however, no evidence
to support its use
• Prognosis:
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30-40% of patients achieve full recovery at 12 months
30-40% fatality rate
30-40% will have long term neurological deficits
Long term neurological sequela: fatigue, word finding difficulty