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A 58 yo female with mental status changes

A 58 yo female with mental status changes. Aram Harijan UNC MS3 09/26/07. HPI 9/10/07. Relevant PMH of DM, SLE, Graves, TIA, UTI Subjective fever X 1 week + intermittent shakes Confused, slurring, dizzy X 2 days; “Talking out of her head” per husband

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A 58 yo female with mental status changes

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  1. A 58 yo female with mental status changes Aram Harijan UNC MS3 09/26/07

  2. HPI 9/10/07 • Relevant PMH of DM, SLE, Graves, TIA, UTI • Subjective fever X 1 week + intermittent shakes • Confused, slurring, dizzy X 2 days; “Talking out of her head” per husband • Similar symptoms twice in the past; once last year and once the year before. • Endorses urinary frequency, dark urine, lower abd pain, bilateral shoulder pain, bilateral rib pain with deep inspiration and laughing • Denies urgency, hematuria, cough, chest pain, SOB, chills, n/v, HA, runny nose, sore throat. • In ED, levofloxacin 500 mg IV x1, solumedrol 150 mg IV x1, tylenol 650 mg po x1

  3. PMH • DM, SLE, History of TIAs, History of UTIs, • Graves disease s/p radioablation hypothyroidism; not on meds • Restrictive lung disease 2/2 SLE • Depression • GERD • RA • Shingles • Endometrial cancer s/p total abd hysterectomy 1996 • Chronic thrombocytopenia, anemia • Chronic low-grade myositis • Diastolic dysfunction • Hypertension • Mitral regurg • Osteoporosis

  4. Social/Family History • Lives with husband in Raleigh • Retired teacher/minister • No T/A/D • No history of recent travel. • One daughter. • Mother died at 50s of bone cancer

  5. Medications • Actonel 35 mg po Qweek • Albuterol 90 mcg inhaler q6hours + prn • Calcium carbonate 1.25 GM • Multivitamins + Vit D • Furosemide 40 mg po qd • Hydrocodone-APAP 5/325 BID • Hydroxychloroquine 200 mg QD • Omeprazole 20 mg QD • Ponaris nasal emollient • Prednisone 20 mg QD • Systane 0.3-0.4 % eye drop

  6. ROS PE • Vitals: 39.3 P 137 RR 40 BP 143/90 O2 sat 95% RA • General: AAF lying in bed in NAD • Eyes:PERRL, EOMI, no photophobia +Proptosis • Neck:Negative Brudzinski +Thyromegaly • CV: RRR, No murmurs, rubs. +Chest wall TTP bilaterally • Pulm:+decreased breath sounds in LLL • Skin: No lesions • Psych:Alert and oriented X3, labile affect, slow to answer questions • Extremeties: 1+ edema LE bilaterally • Mostly negative except per HPI • Neck: No stiffness • Endocrine: Often feels cold.

  7. Laboratory 9/11/07 • Urinalysis • 1+ LE • +nitrites • 2+ protein • 2+ blood • 30 WBCs • 7 RBCs • many bacteria • Glucose 130 • WBC 9.3 • Hemoglobin 13.7 • Platelets 85 • UCx pending • BCx pending • Sputum culture: oropharyngeal flora • No LP

  8. Imaging • CXR • Diminished lung volumes with bibasilar atelectasis and left pleural effusion • LLL pneumonia versus atelectasis • MRA of head • Nonspecific white matter focal flare signal abnormality and cerebral volume loss • Normal circle of Wilis

  9. Discussion When I approach a child, he inspires me two sentiments; tenderness for what he is, and respect for what he may become. -Louis Pasteur

  10. C3 120 C4 < 8 (as in the past) CRP 27 ESR 120 T4, total 4.6 (L) T4, free 0.68 (L) TSH, 0.32 (L) T3, free 1.8 (L) Further workup

  11. E. Coli Urine culture 9/12

  12. Blood culture 9/13 • Blood culture: L. monocytogenes

  13. Non-ID causes Vascular: TIA, vascular dementia, HF, dehydration Infection Neoplasm: paraneoplastic, mass effect, lymphomas, metastatic cancer Drugs (withdrawl, toxicity) Inflammatory: vasculitides Congenital: IEOM Autoimmune Trauma: IC bleeds Endocrine/Metabolic: DM, +/-thyroid, lung/liver/kidney failure. ID causes Septic encephalitis: UTI, pneumo, sepsis, bacterial peritonitis Brain:“-itis”, empyema, abscess Treatable aseptic: HSV, VZV EBV, CMV, measles, mumps, viruses named after places, Arboviruses, Rabies HIV: toxo, tb, syphilis, lymphomas, crypto, asper, norcardia, Parasites: cysticercosis Bacterial: S. pneumo, N. meningitidis, H. influenzae, enteric GNR, L. monocytogenes. Mental Status Changes

  14. GPR Intracellular Tumbling motility Narrow zone of hemolysis on sheep blood agar and the production of acid from glucose, maltose, L-rhamnose, and -methyl-D-mannoside but not from D-xylose. Somatic (o) and flagella (H) antigens. Serotypes 1/2a, 1/2b, 4b. Listeria monocytogenes

  15. Internalin - phagocytosis Listeriolysin O, phospholipases - escape phagosome Flagella - cell to cell movement Not eliminated by antibodies Intracellular = Think cell-mediated

  16. 1985 LA : 142 cases; 48 deaths or still births (20 fetus, 10 neonates, 18 nonpreg) France 1992 : 279 cases; 63 deaths Food-borne epidemics

  17. CSF or blood culture Dx. 3-5 per million in US Most sporadic Epidemiology - Invasive listeriosis

  18. 9 birth complications / 100k 20% fatal or result in stillbirth Epidemiology - Perinatal listeriosis

  19. Pregnancy-associated listeriosis Most detected in 3rd trimester 1/2-2/3 experience mild illness - fever, myalgia, malaise, backache, +/- diarrhea, abd pain, n/v Bacteremia -> transplantal spread -> chorioamnionitis, premature, IU demise, newborn disease (meningitis <1 months) Neonates: early granulomatosis infantisepticum (<1 wk), late meningitis (>1 wk) Clinical presentation - Pregnancy

  20. Refresher

  21. Most common - bacteremic infection without focus Febrile, appear extremely ill Myalgia, n/v, diarrhea 2nd MC - CNS infection Meningitis MC: acute or subacute Fever, HA, altered level of consciousness CSF: pleocytosis, ^ protein, nml glucose. Gram positive 25%. Rarely monocytosis Meningoencephalitis, cerebritis, various abscesses. Fever, ataxia, seizures, personality changes, coma Nuchal rigidity rare in nonmeningitic inf. BCx > LP Clin. presentation - Immunocompromised

  22. Endocarditis Prosthetic/damaged valves Predilection for left side of heart Systemic embolization often present Focal infections Acute diarrheal syndrome in immunocompetent. Clin Present. Continued

  23. Immunocompetent Amp (2 g IV q4h) or pen G (15-20m unit IV divided in six doses qd) X 2-3 wk p defervescence Immunosuppressed + meningitis Amp + gentamicin (1.3 mg/kg IV q8h) X 4-6 wks Neonatal: amp X 2-3 wks Pregnant: amp X 2 wk; erythromycin for pen allergy No cephalosporins Treatment

  24. No unpasteurized milk or products No soft cheese Reheat food until steam Don’t eat cold meat Don’t eat mush food Food industry standards and regulations Prevention

  25. Progressive improvements in mentation MMSE 30 on day 5 hospitalization Currently @ SNF for completion of ABX tx Epilogue

  26. References • Harrison’s Principles of Internal Medicine 16th Ed. Chapter 123. • Book available online via the UNC-CH Libraries

  27. Search PubMed • Listeria Meningitis • Case Reports • Reviews • Differential Diagnosis • Drug Therapy

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