Persistent vegetative state with encephalitis in a pregnant woman with successful fetal outcome

Abstract

Case report A 28 year old woman, gravida 3, para 2, consulted her physician at 22 weeks of gestation for a flulike syndrome. Pharyngitis was suspected and antibiotics were given. Vomiting, vertigo, left sided paraesthesia and dysarthria developed over the next few days. The patient was referred to our centre in December 2001. At the first examination, she was conscious, with confusion and fever. She had an internuclear ophthalmoplegia with monocular nystagmus; her gait was ataxic, without dysmetria. She presented left hemiparesis, dysphagia and false passage. During the next week, the neurological status worsened: the patient was able to open her eyes but unable to respond to simple commands; she became unconscious with finally a persistent vegetative status. The patient was admitted to the Department of Neurosurgery, which is located immediately beside the obstetric unit at our institution. Her neurological status remained unchanged for 10 weeks. The brain magnetic resonance imaging (MRI) showed numerous hypersignals in the cerebral trunk, corpus callosum and basal hemispheric brain (Fig. 1). Routine biochemical tests were normal. The analysis of the cerebrospinal fluid showed a non-specific reaction (normal glucose, 1.5 g/L protein, 11–30 leucocytes/mm 3 ). The immunologic tests found high concentrations of IgM against Epstein–Barr virus and cytomegalovirus and an antiprothrombin-like circulating anticoagulant. The direct viral and bacteriological cultures were negative. The diagnosis was therefore encephalitis of unknown origin. The patient was separated and not married to the father of the fetus. Her parents were the legal decision makers in this case. They received complete information on medical findings and data of the literature, and we told them that in our opinion, the pregnancy should be continued. However, the parents wrote to political and medical authorities to request for the pregnancy to be terminated. We asked a judge to appoint an independent arbiter. We also asked for an opinion from the National Academy of Medicine and National Committee of Ethics. All these authorities agreed