Case-Based Modules > Case 34

A 67 year-old man with RA (on methotrexate), GERD, and OSA is brought to the ED with progressive confusion over the last two days. His daughter said it got especially bad today and he's unable to care for himself.

In the ED, he undergoes a non-contrast head CT, which is unrevealing. Vitals are notable for BP 110/65, HR 105, RR 10, SpO2 100%, T 38.1C. The ED consults you for help with determining the etiology and management for his acute encephalopathy. You're finishing up seeing another consult, but as you do so, they page you back to tell you that the patient just had a seizure.

In the ED, he undergoes a non-contrast head CT, which is unrevealing. Vitals are notable for BP 110/65, HR 105, RR 10, SpO2 100%, T 38.1C. The ED consults you for help with determining the etiology and management for his acute encephalopathy. You're finishing up seeing another neuro consult (you're on the consult team for the week), but as you do so, they page you back to tell you that the patient just had a seizure.

On your arrival, you see the patient is unresponsive. The ED nurse begins to administer 2mg of IV lorazepam. He tells you that the patient's convulsions stopped after about 1 minute. You are able to ask him to belay that order as the patient may not actually need it. On your exam, the patient is somnolent. He grunts when you pinch his trapezius. He initially has no motor response to noxious stimuli. He has no airway sounds and he has non-labored respirations. You observe him over the next ten minutes, and in this time, his mentation gradually improves. He remains confused, as he was prior to this.

What do you make of his presentation so far?

This is a 67 year-old man who is actively immunosuppressed and has had an acute onset of progressive encephalopathy (confusion and then somnolence), and now he's just had a convulsive seizure. Vitals are normal aside from an elevated temperature, likely a true fever. Our differential diagnosis must include an infectious meningoencephalitis (encephalopathy + fever + seizure). Time course is quite acute, but could still consider progressive brain tumor that's finally reached the threshold for causing such dramatic signs/symptoms. Something inflammatory like demyelination is plausible (associated with methotrexate, though less likely as he's not on a high-dose or intrathecal regimen).


What are your recommendations?

This patient needs to be closely monitored in this acute phase to ensure that his mentation continues to clear; if this doesn't happen, then intubation for airway protection could be required. In terms of diagnostic workup, we can initiate cEEG, mainly to answer the question of whether he's at risk for non-convulsive seizures considering he's had progressive confusion over the last two days. We should make sure to obtain CSF studies, as infeectious meningoencephalitis is at the top of our list of things to urgently rule out. Because of the seizure, we'll get an MRI brain at some point soon when safe; this may also help identify any complications of meningoencephalitis.

So, you recommend that the ED order cEEG. You also recommend a normal volume LP (6mL should be adequate), with the following CSF studies: cell count and differential, protein, glucose, Gram stain and culture, HSV PCR. You admit the patient to the floor. Before you go, you do ask the ED to start broad-spectrum antimicrobials for community-acquired meningoencephalitis: IV vancomycin, ceftriaxone, ampicillin, acyclovir.

> Click here to continue