Vasavi - Charaka Case Presentation

01
A CASE OF VIRAL
MENINGO- ENCEPHALITIS
WITH ARDS
Dr.ACHANTA VASAVI LAKSHMI

POST GRADUATE
GENERAL MEDICINE
MODERATOR : DR.T.GOPI M.D.
A Case of Viral Meningo - Encephalitis 02
• Name: XXXXXX
• Age:15 Years
• Sex: Male
• Address: Rajahmundry
CHIEF • Occupation: Student
COMPLAINTS • Chief complaints:

⚬ Fever since 7 days
⚬ Vomitings since 4 days
⚬ Headache and altered
sensorium since 1 day
HISTORY OF PRESENT ILLNESS

• Patient presented to triage on 12/09/2022 with fever for 1 week and altered sensorium since morning.
• He was apparently normal 1 week back then he developed fever for 7 days for which he was treated outside referred
to GSL in view of fever and altered sensorium

• Fever which was insidious in onset , high grade , intermittent type, relieved with medication, without any diurnal
variation associated with chills and rigors .

• H/O vomitings since 4 days, 3-4 episodes/day immediately after taking food ,vomitus containing food particles , non
bilious, non projectile type non bloodstained

HISTORY OF PRESENT ILLNESS contd.

• H/O headache - frontotemporal type, insidious onset since 1 day ,associated with stiffness of neck movements , not
associated with blurring of vision, photophobia / phonophobia

• H/O altered sensorium since morning.
• No H/O rash over body , weakness of limbs , uprolling of eyeballs , tongue bite, frothing over mouth, speech
disturbances , recent head trauma, ear infections

PAST HISTORY
• No H/O similar complaints in past • Birth History -
• 2 doses of covid vaccination taken ⚬ Born to non-consanguinous married couple
• No H/O trauma ⚬ Normal vaginal delivery
• Not a known case of DM/HTN/PTB/BA/SEIZURES ⚬ No complications during delivery
• Family History - Not significant • Developmental History - Normal
• Drug History - Not on any medications • Vaccination History - fully immunised (IAP)
PERSONAL HISTORY
• Patient consumes mixed diet
• Bowel and bladder habits are regular
• Sleep and appetite adequate

GENERAL EXAMINATION
• Patient was moderately built and ill nourished • Vitals at admission:
• Body weight - 45 kgs ⚬ BP - 100/60 mmhg ,
• Height - 158 cms ⚬ PR - 110/min,
• BMI - 18 Kg/m2 ⚬ RR - 22/min ,
• BSA - 1.41 m2 ⚬ Temperature - 101 F ,
• His sensorium was altered, incoherent, disoriented to time place ⚬ RBS - 108 mg/dl
and person ⚬ SpO2 - 92 % on room air
⚬ No pallor, icterus, cyanosis, clubbing, lymphadenopa
pedal edema
SYSTEMIC EXAMINATION - CNS EXAMINATION

• GCS • Motor system
⚬ E2V3M4 (9/15) ⚬ Bulk : Symmetric on both sides
• Higher mental functions ⚬ Tone : Normal
⚬ Patient was drowsy, Disoriented to time, Place and Person's ⚬ Power : Right Left
speech was incoherent • UL 5/5 5/5

• Cranial nerve examination • LL 5/5 5/5
⚬ Couldn’t be tested ⚬ Reflexes
￭ Superficial reflexes - Present
￭ Plantars - R- flexor , L- Flexor.
￭ Deep tendon reflexes - Present - +2


• Sensory system • Signs of meningeal irritation
⚬ Couldn’t be tested ⚬ Neck stiffness - Present
• Cerebellar signs ⚬ Kernigs - Positive
⚬ Dysarthria - Present ⚬ Brudzinski - Positive
• Autonomic nervous system • Examination of spine and cranium
⚬ No postural hypotension ⚬ Spine -No bony deformities / gibbus
⚬ No abnormal sweating ⚬ Cranium - No bony abnormalities


• CVS • P/A
⚬ JVP - normal ⚬ Soft , Non tender
⚬ First , Second heart sounds are heard
⚬ No organomegaly
⚬ No murmurs
⚬ Bowel sounds are heard
• RS
⚬ Bilateral air entry present
⚬ Normal vesicular breath sounds heard
⚬ No added sounds
PROVISIONAL DIAGNOSIS
• MENINGITIS
• CEREBRAL MALARIA
• ENCEPHALITIS
WORKUP ON THE DAY OF ADMISSION

• Patient was admitted and Routine Blood investigations along with specific tests to rule out malaria, dengue, widal &
blood and urine cultures were sent. Ryles and foleys were inserted
Hb -12.7 g/dl
T.Bilirubin - 0.5 mg/dl
PCV - 39 CUE
Direct bilirubin - 0.2 mg/dl
TLC - 7400 cells/mm3 Albumin -+
SGOT - 155 IU/L
N,L,E,M,B- 69,27,01,03 Glucose - Nil
SGPT - 134 IU/L
Platelets - 1.4 lakhs/mm3 RBC - Nil
ALP - 186 IU/L
Sr.creat -0.7 mg/dl Pus cells - 0-1
Albumin - 3 g/dl
Bl.Urea- 29 mg/dl Epithelial cells - 1-2
RBS - 90 mg/dl
Sr.sodium - 146 meq/L
Sr.potassium -4.2 meq/L

DAY 1 - LABS
CSF protien -162mg/dL
Dengue NS1Ag - Negative
CSF sugar -35mg/dl
Dengue IgM, Ig - Negative
CSF sugar/blood sugar - 0.6
Malarial Ag - Negative
CSF TLC - 25cells/mm3
smear for MP - Negative
Lymphocytes - 25cells/mm3
Widal
CSF ADA - 8.1
Salmonella typhi H - 1:80
CSF CBNAAT - negative
Salmonella typhi O - 1:160
CSF RTPCR for TB - negative
• Interpretation: High protein, low normal sugars probably Viral Meningitis.

DAY 1 - LABS
Viral markers
• HIV/HbsAg/HCV - Non reactive
• ECG - Normal sinus rhythm
• 2D Echo - No RWMA , Good LV function (EF- 65%), No pericardial effusion
• USG ABDOMEN - Mild ascites

CHEST X-RAY
DAY 1 - VITALS
GCS - E2V3M4 - 9/15
Patient was drowsy but arousable , speech was incoherent
Vitals:
• BP - 90/60 mmHg
• PR - 110/min
• RR - 22/min
• SPO2 - 96% on room air
• GRBS - 57 mg/dl
• Temperature - 103 F
ON DAY 1
He was started on
• IV FLUIDS • Inj. 25% DEXTROSE 100 ml iv 8th hourly
• Inj. CEFTRIAXONE 2 gm iv 12th hourly • Inj. MANNITOL 20% 100 ml iv 8th hourly
• Inj. ACYCLOVIR 500 mg iv 8th hourly • Inj. PARACETAMOL 1gm iv SOS
• Inj. ARTESUNATE 120 mg iv OD • Tab .PARACETAMOL 650 mg RT 8th hourly
• Inj. PHENYTOIN 100 mg iv 8th hourly • Ryles feed 200ml 2hrly
• Inj.PANTOPRAZOLE 40 mg iv OD
ON DAY 2
• Patient condition deteriorated in view of poor sensorium and severe hypoxemia patient was shifted to ICU for intensive
monitoring. Patient developed a episode of generalised tonic clonic seizures
BP - 100/70 mmHg ABG
PR - 106/min pH - 7.31
RR - 32/min pCO2 - 46
Temperature - 102 F pO2 - 96
SpO2 - 92% on 8 lit O2 HCO3 - 28.3
GRBS - 97mg/dl FiO2 - 52%
PaO2/FiO2 - 184
ON DAY 2
Hb - 10.5gm/dl T.Bilirubin 0.4mg/dl
PCV - 32 Direct bilirubin 0.2mg/dl
TLC - 4,100cells/mm3 SGOT 272IU/L
SGPT 148IU/L
N,L,E,M,B - 55,41,01,03
ALP 167IU/L
Platelets - 70000 - 75000cells/mm3
Albumin 2.2gm/dl
Sr.creat - 0.6mg//dl
Total proteins 5.6gm/dl
Bl.Urea - 28mg/dl
RBS 113mg/dl
Sr.sodium - 144meq/l
LDH 1870IU/L
Sr.potassium - 4.4meq/l
D dimer 1450 ng/ml
ON DAY 2
CT brain showed mild cerebral edema .
Treatment :
• Antimicrobials were escalated to
⚬ Inj. MEROPENEM 1gm iv bd
⚬ Inj. PHENYTOIN 100mg iv tid

ON DAY 3
• He became tachypneic, tachycardic ,hypotensive and hypoxemic for which he was intubated
• Central venous access was established through which ionotropic support was started
Inj.NORADRENALINE (2 amp in 50 ml NS) @ 3ml//hr.

• Fever spikes continued
• Hypoglycemic episodes were present for which he was given 25% Dextrose
DAY 3 - VITALS
Vitals: ABG
• BP - 90/60 mmHg • pH - 7.45
• PR - 124/min • pCO2 - 39.2
• RR - 20/min • HCO3 - 30.4
• Temp - 101 F • pO2 - 96%
• SpO2 - 83% on 15 lit oxygen • FiO2 - 60%
• GRBS - 231 mg/dl • P/F - 160

CHEST X-RAY
Ventilator Mode Day 2

V- SIMV
FiO2- 80%
PEEP- 5cm H2O
P support 10 cm H2O
Tidal volume - 400ml
Ventilator Mode Day 3

VAC mode
FiO2 50%
Tidal volume - 380ml
PEEP- 5cm H2O
P support 10 cm H2O
ON DAY 3
• Point of care screening echo - normal
• Despite invasive ventilation hypoxemia worsened FiO2 requirement was high to maintain saturation .
• HRCT chest was done

DAY 3 - HRCT CHEST
• Multi focal patchy consolidations and ground glass
opacities in bilateral lung fields likely Infective etiology -
ARDS
• Bilateral mild pleural effusions(R>L)
ON DAY 3
• Inj. NORADRENALINE (2 amp in 50 ml NS) @ 3ml//hr.
• Inj. MEROPENEM 1gm iv bd,
• Inj. VANCOMYCIN 500mg iv bd ,
• Inj. PHENYTOIN 100mg iv tid
• Inj. 25 % DEXTROSE iv TID
• Inj. ACYCLOVIR 500mg iv tid,
• Inj. METRONIDAZOLE 500mg iv tid,
• Inj. DOXYCYCLINE 100mg iv bd.
• Inj. VITAMIN C 500 mg ivTID

CONCERNS ON DAY 4
• Hemodynamic instability , recurrent hypoglycemic episodes , worsening hypoxemia despite intermittent
positive pressure ventilation and persistent fever spikes
PR - 88/min pH- 7.26
RR - 22/min pCO2 - 43
Temp - 103F HCO3 - 32
SpO2 - 100% @ FiO2 50% pO2 - 53
GRBS - 90 mg/dl Fio2 - 50%
PaO2/FiO2 - 106
CONCERNS ON DAY 4 CONTD.

• Hemodynamic instability , recurrent hypoglycemic episodes , worsening hypoxemia despite intermittent
positive pressure ventilation and persistent fever spikes
PR - 88/min pH- 7.26
RR - 22/min pCO2 - 43
Temp - 103F HCO3 - 32
SpO2 - 100% @ FiO2 50% pO2 - 53
GRBS - 90 mg/dl Fio2 - 50%
PaO2/FiO2 - 106
CONCERNS ON DAY 4 CONTD.

• Vasopressor support continued
• Prone ventilation initiated in view of refractory hypoxemia
• 20% human albumin 100ml was transfused
• 1 unit PRBC transfusion was done

ON DAY 5 - DAY 7
• Clinical condition continued to remain poor. Fever spikes and hypoxemia still persisted Patient was nursed
prone for around 12 hrs/ day for 3 days

ABG
BP- 120/70 mmHg
pH - 7.34
PR - 88/min
pCO2 - 40
RR - 22/ min
HCO3 - 28
Temp - 103 F
pO2 - 116
SpO2 - 100% @ 50% FiO2
FiO2 - 50%
GRBS - 90 mg/dl
P/F - 232
• Interpretation: WHERE IS INTERPERTATION VASAVI LAKSHMI ACHANTA ?
Day 5
Mode - SIMV
FiO2 - 50%
TV - 400ml
PEEP - 6cm
Pressure support - 8 cm
ON DAY 8
• Patient condition began to improve and his blood pressures maintained despite of tapering vasopressor support.
• His body temperatures came down and gradually his sensorium, oxygenation improved.
• Patient gradually weaned off from the ventilator.

ON DAY 8 CONTD.
All other antimicrobials continued ABG
BP - 100/70 mmHg pH - 7.35
PR - 87/min pO2 - 100
RR - 17/min pCO2 - 36
Temp - 101 F HCO3 - 28
SpO2 - 100 % @ 40% FiO2 FiO2 - 40%
GRBS - 108 mg/dl P/F - 250

ON DAY 9
• Patient was extubated after successful spontaneous breathing trial.
• Indwelling lines removed. Nutrition and Chest physiotherapy initiated
ABG
BP - 110/70 mmHg
PR - 88/min
pH - 7.43
RR - 24/min
pCO2 - 37
Temp - 99 F
HCO3 - 29
SpO2 - 98% on RA
pO2 - 96
GRBS - 110 mg/dl
Fio2 - 21%
P/F - 457
ON DAY 10
• Post extubation patient saturations maintained 100% on room air
• Blood culture report showed klebsiella pneumonia with sensitivity to piperacillin and tazobactum.
• Antibiotics were de-escalated to Inj. PIPTAZ 4.5 gm IV tid based on blood culture and sensitivity report
• Inj.meropenem, vancomycin, were stopped
• Patient was encouraged to mobilise and physiotherapy continued

ON DAY 11
• His condition improved , he was shifted to step-down
• He was initiated on oral drugs
• Patient continued to have difficulty in speaking , while other parameters improved without any focal
neurological deficit
• MRI brain was sent to evaluate which showed T2 flair subtle hyperintensities in B/L parieto occipital
lobes
• B/L cerebellar parenchymal hyperintensities
• He was ambulates with support

MRI BRAIN
DAY 12 - DAY 15
• In view of his staccato speech , speech therapy initiated
• After Neurology consult for his staccato speech he was diagnosed to have cerebellitis , according to neurologist
advise he was continued with Acyclovir for 3 weeks duration

• He was encouraged to take nutrition and ambulated with support
• All his injectables were tapered to oral tablets. He was on
⚬ Tab. ACYCLOVIR 400MG TID
⚬ Tab. PHENYTOIN 100mg TID
⚬ Tab. PANTOP 40 mg OD
⚬ Tab. NEUROBION FORTE OD
⚬ Syp. PCM 10ml PO TID

ON DAY 16
• Condition at discharge
• Ambulant with minimal support
• Dysarthria persisted
• He was advised to take protein rich diet and his speech physiotherapy was continued
DAY 12 - DAY 15
• In view of his staccato speech , speech therapy initiated
• After Neurology consult for his staccato speech he was diagnosed to have cerebellitis , according to neurologist
advise he was continued with Acyclovir for 3 weeks duration

• He was encouraged to take nutrition and ambulated with support
• All his injectables were tapered to oral tablets. He was on
⚬ Tab. ACYCLOVIR 400MG TID
⚬ Tab. PHENYTOIN 100mg TID
⚬ Tab. PANTOP 40 mg OD
⚬ Tab. NEUROBION FORTE OD
⚬ Syp. PCM 10ml PO TID

INVESTIGATIONS
DATE DAY 1 DAY 2 DAY 5 DAY 8 DAY 12
Hb 12.7gm/dl 10.5 gm/dl 10.8gm/dl 11.3gm/dl 11.4gm/dl
PCV 39 32 32 34.9 35.2
TLC 7400cells/mm3 41,00cells/mm3 6300cells/mm3 3500cells/mm3 6300cells/mm3
N,L,E,M,B 69,27,01,03 55,41,01,03 59,38,01,02 66,33,01,0 70,25,03,02
platelets 1.4lacs/mm3 70,000-75,000cells/m3 85,000cells/mm3 1.79lacs/mm3 3.5lacs/mm3
Sr.creat 0.7mg/dl 0.6mg/dl 0.4mg/dl 0.5 mg/dl 0.5mg/dl
Bl.Urea 29mg/dl 28mg/dl 23mg/dl 31mg/dl
Sr.sodium 146mg/dl 144mg/dl 148mg/dl 134mg/dl 135mg/dl
Sr.potassium 4.2mg/dl 4.4mg/dl 3.4mg/dl 3.4mg/dl 4.2mg/dl
DATE DAY 1 DAY 2 DAY 10
T.Bilirubin 0.5mg/dl 0.4mg/dl 0.7mg/dl
Direct bilirubin 0.2mg/dl 0.2mg/dl 0.4mgdl
SGOT 155IU/L 272IU/L 93IU/L
SGPT 134IU/L 148IU/L 127IU/L
ALP 186IU/L 167IU/L 96IU/L
Albumin 3gm/dl 2.2gm/dl 3.4gm/dl
RBS 90mg/dl 113mg/dl 124mg/dl

CUE DAY 1
albumin +
glucose nil
RBC nil
Pus cells 0-1
Epithelial cells 1-2

DAY 1
Dengue NS1Ag NR
Dengue IgM, Ig NR
Malarial Ag & smear for MP NR
CSF protien 162gm/dl
CSF sugar 35gm/dl
CSF TLC 25All are Lymphocytes
CSF ADA 8.1
CSF CBNAAT negative
CSF RTPCR negative

DAY 2 3 4 5 6 7 8 9
pH 7.31 7.45 7.26 7.34 7.38 7.41 7.35 7.43
pCO2 46 39.2 43 40 39 35 36 37
HCO3 28.3 30.4 32 28 31 24 28 29
pO2 96 96 53 116 104 114 100 96
FiO2 52 60 50 50 40 40 21
P/F 184 160 106 232 262 285 250 457

FIRST FOLLOW UP
• His speech improved on his first follow up after discharge
VASAVI LAKSHMI ACHANTA.

Vasavi - Charaka Case Presentation

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01

Dr.ACHANTA VASAVI LAKSHMI

COMPLAINTS • Chief complaints:

HISTORY OF PRESENT ILLNESS

to GSL in view of fever and altered sensorium

variation associated with chills and rigors .

bilious, non projectile type non bloodstained

HISTORY OF PRESENT ILLNESS contd.

associated with blurring of vision, photophobia / phonophobia

disturbances , recent head trauma, ear infections

• 2 doses of covid vaccination taken ⚬ Born to non-consanguinous married couple

• No H/O trauma ⚬ Normal vaginal delivery

• Not a known case of DM/HTN/PTB/BA/SEIZURES ⚬ No complications during delivery

• Family History - Not significant • Developmental History - Normal

• Bowel and bladder habits are regular

• Sleep and appetite adequate

• Body weight - 45 kgs ⚬ BP - 100/60 mmhg ,

• Height - 158 cms ⚬ PR - 110/min,

• BMI - 18 Kg/m2 ⚬ RR - 22/min ,

• BSA - 1.41 m2 ⚬ Temperature - 101 F ,

and person ⚬ SpO2 - 92 % on room air

⚬ No pallor, icterus, cyanosis, clubbing, lymphadenopa

SYSTEMIC EXAMINATION - CNS EXAMINATION

⚬ E2V3M4 (9/15) ⚬ Bulk : Symmetric on both sides

• Higher mental functions ⚬ Tone : Normal

speech was incoherent • UL 5/5 5/5

￭ Superficial reflexes - Present

￭ Plantars - R- flexor , L- Flexor.

￭ Deep tendon reflexes - Present - +2

SYSTEMIC EXAMINATION - CNS EXAMINATION

⚬ Couldn’t be tested ⚬ Neck stiffness - Present

• Cerebellar signs ⚬ Kernigs - Positive

⚬ Dysarthria - Present ⚬ Brudzinski - Positive

• Autonomic nervous system • Examination of spine and cranium

⚬ No postural hypotension ⚬ Spine -No bony deformities / gibbus

⚬ No abnormal sweating ⚬ Cranium - No bony abnormalities

SYSTEMIC EXAMINATION - CNS EXAMINATION

⚬ Bilateral air entry present

⚬ Normal vesicular breath sounds heard

WORKUP ON THE DAY OF ADMISSION

Sr.potassium -4.2 meq/L

• Interpretation: High protein, low normal sugars probably Viral Meningitis.

• ECG - Normal sinus rhythm

• 2D Echo - No RWMA , Good LV function (EF- 65%), No pericardial effusion

• USG ABDOMEN - Mild ascites

Patient was drowsy but arousable , speech was incoherent

• SPO2 - 96% on room air

• Inj. ACYCLOVIR 500 mg iv 8th hourly • Inj. PARACETAMOL 1gm iv SOS

• Inj. ARTESUNATE 120 mg iv OD • Tab .PARACETAMOL 650 mg RT 8th hourly

• Inj. PHENYTOIN 100 mg iv 8th hourly • Ryles feed 200ml 2hrly

monitoring. Patient developed a episode of generalised tonic clonic seizures

BP - 100/70 mmHg ABG

Temperature - 102 F pO2 - 96

SpO2 - 92% on 8 lit O2 HCO3 - 28.3

GRBS - 97mg/dl FiO2 - 52%

PCV - 32 Direct bilirubin 0.2mg/dl

TLC - 4,100cells/mm3 SGOT 272IU/L

⚬ Inj. MEROPENEM 1gm iv bd

⚬ Inj. PHENYTOIN 100mg iv tid

Inj.NORADRENALINE (2 amp in 50 ml NS) @ 3ml//hr.

• PR - 124/min • pCO2 - 39.2

• RR - 20/min • HCO3 - 30.4

• Temp - 101 F • pO2 - 96%