MR with Justin: An odd case of altered mental status

An older woman w/ lupus, sjogrens, MS, and recent resection of a parathyroid adenoma presents with AMS and fever to 103. She had an LP with only 7 WBCs, and her symptoms (and fever) quickly improved before receiving antibiotics. She was ultimately treated for ~24h with acyclovir, but given her rapid improvement she was discharged to home on HD1 with the thought that this was all due to a transient viral infection, though lupus cerebritis was also considered.

 

*The mnemonic for AMS is my favorite mnemonic of all. I use it every time to make sure I’m not missing anything.

 

The mnemonic: MOIST (or MISTO for people that hate that word)

M etabolic (uremia, Na, Ca, thyroid, glucose)

O xygen + hypercarbia (get that blood gas)

I nfection

S tructural (stroke, subdural, seizure)

T oxin

7/21 Morning Report w/ Lenie and Dr. Robbins: AMS in a newly diagnosed cirrhotic

A middle aged man w/ HCV and excessive etoh use presents with altered mental status, found to have liver failure of unclear chronicity. Already growing GNRs in blood!

*The evidence behind pharmacologic treatments for alcoholic hepatitis is shotty; a 2015 NEJM paper showed that prednisone showed trends of decreased mortality at 28 days that did not reach significance. Prednisone should not be given in the setting of suspected infection. Pentoxifylline does not improve survival. http://www.nejm.org/doi/10.1056/NEJMoa1412278