Monday, 8 December 2008

December Case - Think Carefully !

Dear Bloggers

The following case has been anonymised for the purposes of protecting patient confidentiality.

This 70 year old female patient was admitted into a distant hospital with fever which had begun several days before. The fever reached a height of 39 degrees C when at home, which prompted the patient to seek medical advice.

The patient denied respiratory, urinary, or gastrointestinal symptoms. There were no sweats, rigors or weight loss. The patient denied headache, neck stiffness and photophobia. There was no complaint of any skin, joint or muscle problems. There was no history of foreign travel, no sick contact, no insect bites and no sexual intercourse in over 10 years.

There was no previous medical history of note and the patient was taking no regular medications.

There was no family history of note and the patient was a non-drinker and non-smoker. She lived with her husband in a house, was fully independent and had good family support from her children and other relatives who all lived nearby.

On Examination

- Slightly unwell; No JACCOL. Several splinter haemorrhages in the nails. Several Janeway lesions on the palms.

- Cold finger and toes, Pulse 100/min regular, BP 100/80, JVP not raised, dry skin, dry mucous membranes, tenting sign positive, no axillary sweating. Heart sounds 1 + 2 + no added sounds. Levine II/VI pansystolic murmur in the apex area radiating to the left axilla accentuated on expiration. No evidence of peripheral oedema or DVT.

- Respiratory Rate 16/min, Sats 98% on room air, Trachea central, expansion normal, Percussion sound normal, auscaultation normal vesicular breath sounds.

Non-distended, Soft, No hepatosplenomegaly, No Masses, No renal angle tenderness, bowel sounds normal. Rectal examination - no masses, no posterior cervical motion tenderness, no blood.

- All joints normal range of motion and no warmth. No deformity. No Muscular problem identified.

- No tremor, no goitre or neck pain on examination.

CNS / PNS - No neck stiffness, no photophobia, Kernig Sign negative, Brudinski Sign negative. Tone - normal throughout
Power - 5/5 throughout
- normal ++ in all limbs

- Normal

- Normal

- plantar flexion bilaterally (negative)

Pupils equal and reactive to light and consensual response.
All cranial nerves seemingly normal throughout.

- no Roth's spots seen. No papilloedema.

Clinical Impression: High suspicion of infective endocarditis.

Blood cultures revealed MSSA in 4 bottles and the patient was commenced on flucloxacillin and gentamicin.

Echocardiogram confirmed the existence of a small vegetation.

However, the patient was not eating or drinking during the hospital admission and intravenous fluids were subsequently commenced. Urine output began to deteriorate and mental status decreased, first with confusion, then stupor and finally with obtundation.

Laboratory studies revealed Hb 18, haematocrit 0.5 and a urine osmolality of 1000.

Repeat neurological examination after several days of admission revealed the following:

GCS - No eye opening, no response to pain, no verbal response.

Cranial nerves: Difficult to examine but pupils equal and reactive to light. Doll's Eye sign positive.

PNS: Tone diffusely decreased, unable to assess power, generalised areflexia, Babinski sign indeterminate bilaterally.

Respiration: Cheyne-Stoke respiration.

A CT brain was performed which showed no abnormality. Lumbar puncture follow-up was again normal. CSF pressure was no measured.

Questions: 1) From the physical examination, which valve is affected by the confirmed endocarditis?

2) From the history and first physical examination, what is the likely aetiology of the other cardiovascular clinical signs (excluding those of endocarditis) and the subsequent loss of consciousness?

3) With the follow-up neurological examination in mind which part of the nervous system has been affected?

4) What would be your next test to confirm your suspicions?

5) What might be the cause(s) of the neurological condition present?

Please note, this is a very difficult case. Please try your best with the limited information available to consider various diagnoses. You never know, you might just be right! Answers this month--- at some point ;-) Please feel free to send me your answers.

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