Acute Altered Mental Status Research Articles

Neurological Diagnostic Testing in Elderly Patients with Acute Altered Mental Status (982)

Neurological Diagnostic Testing in Elderly Patients with Acute Altered Mental Status (982)

Telephonic description of sepsis among callers to an emergency dispatch centre in South Africa.

IntroductionSepsis is an acute, life-threatening condition caused by a dysregulated systemic response to infection. Early medical intervention such as antibiotics and fluid resuscitation can be life-saving. Diagnosis or suspicion of sepsis by an emergency call-taker could potentially improve patient outcome. Therefore, the aim was to determine the keywords used by callers to describe septic patients in South Africa when calling a national private emergency dispatch centre.MethodsA retrospective review of prehospital patient records was completed to identify patients with sepsis in the prehospital environment. A mixed-methods design was employed in two-sequential phases. The first phase was qualitative. Thirty cases of sepsis were randomly selected, and the original call recording was extracted. These recordings were transcribed verbatim and subjected to content analysis to determine keywords of signs and symptoms telephonically. Once keywords were identified, an additional sample of sepsis cases that met inclusion and exclusion criteria were extracted and listened to. The frequency of each of the keywords was quantified.ResultsEleven distinct categories were identified. The most prevalent categories that were used to describe sepsis telephonically were: gastrointestinal symptoms (40%), acute altered mental status (35%), weakness of the legs (33%) and malaise (31%). At least one of these four categories of keywords appeared in 86% of all call recordings.ConclusionIt was found that certain categories appeared in higher frequencies than others so that a pattern could be recognised. Utilising these categories, telephonic recognition algorithms for sepsis could be developed to aid in predicting sepsis over the phone. This would allow for dispatching of the correct level of care immediately and could subsequently have positive effects on patient outcome.

2254 A Rare Case of Valproate-Induced Encephalopathy Requiring Hemofiltration

INTRODUCTION: We present a rare case of acute encephalopathy due to Valproate induced hyperammonemia required Hemofiltration (HF). CASE DESCRIPTION/METHODS: 45-year-old male was brought in by caregiver to the hospital with acute altered mental status, somnolent but arousable. PMHx of CP, Epilepsy, Left sided hemiplegia, Mental retardation, Abscess of thigh and wrist. Medications were Valproate and Phenytion. PE showed stable vitals, confused, was spitting to staff required restraints. Pupils equal, reactive to light. Neurological exam- left sided hemiplegia. Lab showed Na 140, K 4.0, HC03 30, BUN 7, Cr 1.18, Glucose 101, Osmolarity 287, ALT 24, AST 24, T Bil 1.1, Albumin 3.5, Al phos 79, Mg 2.0, lactic 1.2. WBC 6.9, hemoglobin 15.2, platelet 291, INR 1.2, Ammonia 402. Blood & urine culture and toxicology were negative. Acute hepatitis panel was non- reactive, Ceruloplasmin 32, ferritin 33.7, AMA < 20.1, Smooth muscle antibody < 1:40. Valproic acid level 125 mcg/ml (therapeutic level-50-100 mcg/ml). ECG was normal. Head CT showed no acute abnormality. Ultrasound showed fatty infiltration & Cholelithiasis. Unremarkable EGD. Lactulose & xifaxan were given for hyperammonemia, recurrent seizures occurred. RESULTS: Valproate was discontinued. L-carnitine 100 mg/kg IV loading dose was given. Received HF for 3hrs , and supportive care. Ammonia at 2hours post HF was 80. Patient’s mental status improved back to baseline over 24 hours. DISCUSSION: Acute encephalopathy due to valproate induced hyperammonemia required Hemofiltration is very rare. The incidence of valproate-induced hyperammonemia in the general population of patients taking VPA (Valproate acid) is not well established. Most cases of Valproate acid- toxicity are rather benign and resolve with supportive therapy. It is generally accepted that serum level >180 mcg/ml represents a high risk of toxicity. Our case was a first patient without chronic liver disease and valproate level was below high risk for toxicity who presented with acute encephalopathy due to valproate induced hyperammonemia and required Hemofiltration. Care of patients depends upon recognition of those at increased risk, anticipation & prevention, and appropriate response when they occur. Discontinuation of Valproate may require. L-carnitine has a significant mortality benefit in patient severe Valproate toxicity. HF is reserved for severely ill patients who have not responded to less invasive treatment.

Neuroendocrine carcinoma of the colon presenting as acute meningitis

BackgroundNeuroendocrine tumors represent an expansive group of neoplasms that share an etiology of epithelial origin with neuroendocrine differentiation. Poorly-differentiated neuroendocrine carcinomas behave similarly to their aggressive pulmonary counterpart, small cell lung carcinoma. Most patients with gastroenteropancreatic neuroendocrine tumors present with symptoms of metastasis, most commonly to the liver. There have been no case reports, to our knowledge, until now that demonstrate metastasis to the central nervous system.Case presentationA 72-year-old male with poorly-differentiated stage IIIB neuroendocrine carcinoma of the colon presented with acute altered mental status and right facial droop. Head CT was negative for an acute hemorrhagic process without evidence of suspicious lesions. Several days later, the patient developed fever and neck stiffness suspicious for bacterial meningitis. A lumbar puncture procedure was performed. Cytology of the CSF demonstrated metastatic disease to the central nervous system and the final diagnosis of carcinomatous meningitis secondary to metastatic neuroendocrine carcinoma of the colon was made.ConclusionsHigh-grade gastroenteropancreatic neuroendocrine carcinomas most commonly metastasize to the liver, which often corresponds with the patient’s initial presentation. When neuroendocrine tumors do metastasize to the central nervous system, the primaries are most commonly of pulmonary origin. When meningeal metastasis does occur, it commonly presents as neurologic deficits or cerebrovascular events, rarely does meningeal metastasis mimic bacterial meningitis with symptoms of fever, photophobia and meningismus. As neuroendocrine carcinomas have been increasing in incidence over the past several decades, it is important to consider varying metastatic presentations when working up a patient with a diagnosis of neuroendocrine tumor.

Targeting the Blood-Brain Barrier to Prevent Sepsis-Associated Cognitive Impairment.

Sepsis is a systemic inflammatory disease resulting from an infection. This disorder affects 750 000 people annually in the United States and has a 62% rehospitalization rate. Septic symptoms range from typical flu-like symptoms (eg, headache, fever) to a multifactorial syndrome known as sepsis-associated encephalopathy (SAE). Patients with SAE exhibit an acute altered mental status and often have higher mortality and morbidity. In addition, many sepsis survivors are also burdened with long-term cognitive impairment. The mechanisms through which sepsis initiates SAE and promotes long-term cognitive impairment in septic survivors are poorly understood. Due to its unique role as an interface between the brain and the periphery, numerous studies support a regulatory role for the blood-brain barrier (BBB) in the progression of acute and chronic brain dysfunction. In this review, we discuss the current body of literature which supports the BBB as a nexus which integrates signals from the brain and the periphery in sepsis. We highlight key insights on the mechanisms that contribute to the BBB’s role in sepsis which include neuroinflammation, increased barrier permeability, immune cell infiltration, mitochondrial dysfunction, and a potential barrier role for tissue non-specific alkaline phosphatase (TNAP). Finally, we address current drug treatments (eg, antimicrobials and intravenous immunoglobulins) for sepsis and their potential outcomes on brain function. A comprehensive understanding of these mechanisms may enable clinicians to target specific aspects of BBB function as a therapeutic tool to limit long-term cognitive impairment in sepsis survivors.

Recurrent Hepatic Encephalopathy Due to Spontaneous Mesocaval Shunt

Spontaneous portosystemic shunting is a rare entity that can manifest as hepatic encephalopathy (HE) in longstanding liver disease. In cases of severe portal hypertension (pHTN) portal blood flow may reverse with shunting from the portal vein to the inferior vena cava through a portosystemic anastomosis. Shunting allows toxins to accumulate in the systemic circulation leading to encephalopathy. We present a case of spontaneous mesocaval shunting in a patient with recurrent HE. A 76 year old female with history of Hepatitis B cirrhosis, grade II varices, and multiple admissions for HE presented for acute altered mental status for 1 day. At baseline, she is functionally independent and takes lactulose, rifaxamin, nadolol, entecavir, spironolactone, furosemide, and omeprazole. On presentation, she was not alert or orientated, minimally responsive to voice, moving only to pain, eye-blink startle reflex present but without tracking. There were facial spider angiomas, but no jaundice, ascites or asterixis. She was hemodynamically stable with mild pan-elevation of liver tests, hyperammonemia, hypoalbuminemia, macrocytosis with thrombocytopenia and mild coagulopathy. Prior work-up was limited to head CT and abdominal ultrasound due to acute kidney injury, and negative infectious work-up. CT abdomen on presentation revealed stable appearance of cirrhotic liver, as well as pHTN including recanalization of the umbilical vein, esophageal and omental varices, and mesocaval shunt adjacent to the left portal vein consistent with AV shunting. Interventional radiology was consulted for closure of the shunt and after 3 days of medical therapy, her mental status improved to baseline. Initial attempt was unsuccessful in catheterizing the shunt through the inferior vena cava, while a second attempt through the transplenic portogram and embolization of mesocaval shunt was successful. Patient made a stable recovery after the intervention for discharge. Spontaneous mesocaval shunting is a rare collateral circulation that develops between the superior or inferior mesenteric veins and the inferior vena cava. Similar collateral vessels can manifest as patent paraumbical vessels arising from the left portal vein, as seen in this patient. A high index of suspicion in patients with HE with appropriate imaging is needed to make a diagnosis. Treatment of these shunts via occlusion is crucial in reducing the occurrence of recurrent HE in cirrhosis.2292_A Figure 1. Axial CT - Demonstrates large portosystemic shunt arising from the superior mesenteric vein with its confluence at the inferior vena cava. A transplenic approach was utilized to gain access into the portal system and the mesocaval shunt was subselected.2292_B Figure 2. Robust flow was noted on venograms through the shunt pre-embolization. The mesocaval shunt was embolized with multiple coils of varying sizes and with nBCA.2292_C Figure 3. Final venograms demonstrated complete occlusion of the shunt and preferential flow through to the portal vein post-procedure.

S22. Value of emergent EEG in the diagnosis and management of patients with acute altered mental status

Introduction Status epilepticus (SE), considered the most extreme form of a seizure, is one of the most important complications in neurologic patients and an emergency that requires treatment adjustment. In critically ill patients, most of the seizures are non convulsive, and they would be unnoticed without continuous EEG (cEEG) monitoring. It is important to diagnose these patients as early as possible as there is evidence supporting that ictal activity may further compromise at risk brain tissue following acute brain insults. There are countries where cEEG monitoring is easily accessible and it is performed as part of the brain monitoring protocol. Nevertheless, in Spain as in many other countries, cEEG is rarely available, thus, serial routine EEGs are used for this purpose. There is scarce data of the efficiency of routine emergent EEGs (EmEEG) in patients with altered mental status (AMS). Our aim is to reaffirm the utility of EmEEG and to define the clinical spectrum of potentially eligible patients. We want to evaluate whether clinical features can help predict which patients have a high probability of being in NCSE and thus should undergo an emergent EEG. Methods In a first phase, we have reviewed the EEG requested as emergent during business hours and on-call shifts for 6 months. We have included patients with suspicion of status epilepticus, and with an EEG performed within the first 3 h of the request. In a second phase, we are analyzing prospectively patients with the same inclusion criteria, and we are adding the perspective of the clinicians who ordered the test, asking them to anonymously answer a survey, considering whether the results were helpful for the diagnosis and management of these patients. Results In the first phase we have analyzed 232 EmEEGs, 129 during business hours and 103 during call shifts. Twenty-eight (12%) showed an SE, from whom 23 (82.1%) were NCSE and 10 were in patients in coma. NCSE was most frequently detected in patients with a previous lesion (28%), an acute cerebral injury (14%) and a history of epilepsy (14.2%). The most common symptom was an alteration in mental status, followed by motor manifestations, agitation and a language disorder. Conclusion There is a high incidence of NCSE in patients with altered mental status. Obtaining an emergent EEG is not only crucial for the right diagnosis and management of patients in SE, it also provides relevant information in the population of patients with AMS of unknown etiology.

Predictors of abnormal brain computed tomography findings in patients with acute altered mental status in the emergency department.

ObjectiveBrain computed tomography (CT) is commonly performed to diagnose acute altered mental status (AMS), a critically important symptom in many serious diseases. However, negative CT results are common, which result in unnecessary CT use. Therefore, this study aimed to determine the clinical factors associated with positive CT findings.MethodsPatients with acute AMS selected from an emergency department-based registry were retrospectively evaluated. Patients with non-traumatic and noncommunicable diseases on initial presentation and with Glasgow Comal Scale scores of <15 were included in the study.ResultsAmong the 367 brain CT results of patients with AMS during the study period, 146 (39.8%) were positive. In a multivariate analysis, the presence of focal neurologic deficit (odds ratio [OR], 132.6; 95% confidence interval [CI], 37.8 to 464.6), C-reactive protein level <2 mg/dL (OR, 3.9; 95% CI, 1.4 to 10.6), and Glasgow Comal Scale score <9 (OR, 2.4; 95% CI, 1.2 to 4.8) were significantly associated with positive brain CT results.ConclusionThe presence of focal neurologic deficit, initial Glasgow Comal Scale score of <9, and initial C-reactive protein levels of <2 mg/dL can facilitate the selection of brain CT to diagnose patients with acute AMS in the emergency department.

Acute altered mental status secondary to naltrexone-induced opiate withdrawal

Acute altered mental status secondary to naltrexone-induced opiate withdrawal

Teaching neurology to medical students with a simplified version of team-based learning.

To compare the effect of a simplified version of team-based learning (sTBL), an active learning/small group instructional strategy, with that of the traditionally used small group interactive seminars on the acquisition of knowledge and clinical reasoning (CR) skills. Third- and fourth-year medical students (n = 122) were randomly distributed into 2 groups. A crossover design was used in which 2 neurologic topics were taught by sTBL and 2 by small group interactive seminars. Knowledge was assessed with a multiple-choice question examination (MCQE), CR skills with a key feature problem examination (KFPE). Questionnaires were used for further methodologic evaluation. No group differences were found in the MCQE results. sTBL instruction of the topic "acute altered mental status" was associated with a significantly better student performance in the KFPE (p = 0.008), with no differences in the other 3 topics covered. Although both teaching methods were highly rated by the students, a clear majority voted for sTBL as their preferred future teaching method. sTBL served as an equivalent alternative to small group interactive seminars for imparting knowledge and teaching CR skills, and was particularly advantageous for teaching CR in the setting of a complex neurologic topic. Furthermore, students reported a strong preference for the sTBL approach, making it a promising tool for effectively teaching neurology.

Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

BackgroundCurrent sepsis screening tools rely on vital parameters which are, however, normal in one third of patients with serious infections. Therefore, there is a need to include other variables than vital parameters to identify septic patients. Our primary aim was to identify and quantify keywords related to the septic patients’ symptom presentation in the prehospital setting. The secondary aims were to compare keywords in relation to in-hospital mortality and the distribution of keywords in relation to age categories, survivors/ deceased and severe/ non-severe sepsis.MethodsA mixed methods analysis using a sequential exploratory design was performed, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n = 80) from 2012, to identify keywords related to sepsis presentation. Thereafter, the identified keywords were quantified among 359 septic patients from 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code (International Classification of Diseases, Tenth Revision) compatible with sepsis.ResultsThe most common keywords related to septic patients’ symptom presentation were: abnormal/ suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). There was an association between keywords and in-hospital mortality. Symptoms varied between age categories, survivors/ deceased and severe/ non-severe sepsis.DiscussionThis is, to the best of our knowledge, the first study exploring the symptom presentation as documented by EMS, of septic patients in the prehospital setting. Keywords related to patients´ symptom presentation recurred in the EMS records of septic patients, so that a pattern was discernible. In addition, certain symptom presentations were associated with increased in-hospital mortalityConclusionsInformation relating to symptom presentation is not included in current sepsis screening tools. We suggest that keywords related to patients´ symptom presentation could be integrated into screening tools and may thus increase the identification of sepsis, and potentially also identify high-risk patients. However, as a first step, the specificity of these keywords, with respect to sepsis, needs to be examined.

Impact of Asymptomatic Bacteriuria (ASBU) Overtreatment During a Controlled Trial of Antimicrobial Stewardship (AS)

BackgroundWhat are the clinical profiles, outcomes, and antimicrobial costs attributed to patients admitted with presumed urinary tract infection (UTI) but deemed to have “no infection” (NI) by infectious diseases (ID) MD reviewers?MethodsWe performed a review of a subset of patients entered into a randomized, controlled, AS trial that began 7.1.2015. Patients with UTI and 3 other ID syndromes were evaluated by ID MDs within 12–24 hours of receiving empirical antimicrobials. The ID MD designated patients as having NI when a patient lacked compatible symptoms, signs, and laboratory evidence to support a diagnosis of UTI. Patients with NI were tracked but not included in the study intervention to identify AS opportunities.ResultsOver 21 months 6,402 antimicrobial starts were entered into the AS study; 2,196 (34.3%) were UTI. Of these 564 (25.7%) were designated NI. The initial admission of 104 patients designated NI are the subject of this report. Four had possibly clinically significant UTI and were excluded. Of the remaining 100 the average age was 83.6 years, 80% were female and 50% were admitted with acute or chronic altered mental status (dementia, seizure, or stroke); Sixty-five % of urine cultures were positive. The mean Systemic Inflammatory Response Syndrome (SIRS) score was 0.6; the mean quick Sequential Organ Failure Assessment Score (qSOFA) score was 0.9. A mean 3.7 days of antimicrobials were prescribed during the admission; 3.2 additional days at discharge. Of the 100 NI patients followed (up to 21 months following study entry) 34% have died (all-cause), 49% had a subsequent episode of bacteriuria; the mean number of re-admissions per patient was 2.4(range 0–14) and 9% developed C. difficile infection (CDI).ConclusionAS identified a subset of patients treated for UTI but determined by ID MDs as NI, as an elderly, predominantly female cohort, with a high incidence of new or pre-existing neurological conditions, subsequent bacteriuria, re-admission, and short -term mortality. Low SIRS and qSOFA scores in these patients supported a lack of clinically significant infection. AS programs should focus on early efforts to identify ASBU. Preservation of antimicrobial resources, antibiotic cost savings (estimated over 3 years to be $ 450,000), and avoidance of CDI are among the likely benefits.Disclosures All authors: No reported disclosures.

Clinical characteristics of drug intoxicated patients who present to emergency department with acute altered mental status

Clinical characteristics of drug intoxicated patients who present to emergency department with acute altered mental status

Idiopathic Splenic Artery Pseudoaneurysm Rupture as an Uncommon Cause of Hemorrhagic Shock.

Splenic artery pseudoaneurysms are infrequently encountered but critical to recognize. Limited literature to date describes associations with pancreatitis, trauma, and rarely peptic ulcer disease. Hemorrhage and abdominal pain are the most common manifestations. There is typically overt gastrointestinal blood loss but bleeding can also extend into the peritoneum, retroperitoneum, adjacent organs, or even a pseudocyst. Most patients with ruptured splenic artery pseudoaneurysms present with hemodynamic instability. Here, we describe a patient recovering from acute illness in the intensive care unit but with otherwise no obvious risk factors or precipitants for visceral pseudoaneurysm. He presented with acute onset altered mental status, nausea, and worsening back and abdominal pain and was found to be in hypovolemic shock. The patient was urgently stabilized until more detailed imaging could be performed, which ultimately revealed the source of blood loss and explained his rapid decompensation. He was successfully treated with arterial coiling and embolization. Thus, we herein emphasize the importance of prompt recognition of hemorrhagic shock and of aggressive hemodynamic stabilization, as well as a focused diagnostic approach to this problem with specific treatment for splenic artery pseudoaneurysm. Finally, we recommend that multidisciplinary management should be the standard approach in all patients with splenic artery pseudoaneurysm.

Artery of Percheron Infarction as an Unusual Cause of Korsakoff's Syndrome.

The Korsakoff syndrome is defined as “an abnormal mental state in which memory and learning are affected out of all proportion to other cognitive functions in an otherwise alert and responsive patient.” Confabulation refers to false or erroneous memories arising, not deliberately, in the context of a neurological amnesia and is often thought of as pathognomonic of the Korsakoff syndrome. Although the exact pathophysiology is unknown, various studies have identified brain lesions in the thalami, mammillary bodies, and frontal cortex. We report a case of a 68-year-old male presenting with acute altered mental status on July 16, 2015. The neuropsychological dysfunctions included prominent Korsakoff's syndrome, which became apparent when the altered mental status resolved. Amnesia was accompanied by prominent confabulation, disorientation, and lack of insight into his own disability. Neuroradiological data indicated that the intralaminar and dorsomedial nuclei in bilateral thalami were infarcted by occlusion of the artery of Percheron. We believe that ours is one of few reported cases of Korsakoff syndrome in a patient with infarction involving the territory of the artery of Percheron. We conclude that bilateral thalamic lesions could cause Korsakoff's syndrome and the intralaminar and dorsomedial nuclei might be important structures in the pathogenesis of confabulation.

Screening electroencephalograms are feasible in the emergency department

We investigated the feasibility and quality of a wireless, four-channel screening electroencephalogram (EEG) device on patients presenting to the emergency department (ED) with a possible seizure disorder. A convenience sample was used of ED patients presenting with a preliminary diagnosis of syncope, potential partial-complex or generalized seizure disorder, head injury with prolonged symptoms or acute undiagnosed altered mental status. Study patients had a screening EEG in the ED, but the emergency physician and patient were blinded to the results of the EEG so that neither patient care nor disposition were affected by inclusion in the study. A total of 227 patients were enrolled, with a mean age of 56 years. EEG quality was acceptable, i.e. a screening interpretation was able to be provided, in 208 of 227 cases (92%). The EEG interpretation was normal in 65%, identified generalized or focal slowing in 24% and identified sub-clinical epileptiform activity in 12% of patients. Screening EEGs performed in the ED are feasible, can be acquired with acceptable quality, and may identify sub-clinical seizure activity in a significant number of patients.

Altered Mental Status in Emergency Department Patients with Cancer

Introduction Although cancer patients with acute altered mental status (AMS) often present to the emergency department (ED), there is lack of documentation for survival in ED cancer patients with related causes of AMS (structural or metabolic causes). The aim of this study was to evaluate reasons for acute AMS of cancer patients in the ED and their prognostic value for survival. Methods Medical records of cancer patients presenting to ED with acute AMS were reviewed. Patients were divided into 3 groups with respect to AMS etiologies: metabolic causes (Group 1), structural causes (Group 2) and both (Group 3). Median survival time was calculated from the ED presentation and Kaplan-Meier survival curve was generated to demonstrate survival in the three groups. Results Forty-nine patients had only metabolic causes of AMS (Group 1), 21 of whom had more than one metabolic abnormality. Forty-six patients had only structural causes (Group 2) and 7 had both metabolic and structural causes (Group 3). Survival probability at one month was 33% for all patients, 25% for Group 1, 48% for Group 2 and 0% for Group 3 (p=0.11). In Group 1, 32% of patients with only one metabolic disorder and 14% of those with more than one metabolic disorder were alive at one month (p=0.197). Conclusions Regardless of aetiology, cancer patients presented with AMS to the ED usually have poor outcomes. Survival in our ED cancer patients with AMS is not related to the either structural or metabolic causes of AMS. (Hong Kong j.emerg.med. 2014;21:10-15)

Clarithromycin Induced Psychosis in an AIDS Patient Receiving Treatment for Disseminated Mycobacterium avium Intracellulare Infection

Here we present the case of a man who was admitted to the hospital with an extremely low CD4 count and vague symptoms suggestive of an opportunistic infection, who subsequently developed a significant psychosis following standard treatment for Mycobacterium avium intracellulare. The patient was a 48 year old man who presented to the hospital with acute onset altered mental status, diarrhea, and generalized weakness. He had positive blood cultures for Mycobacterium avium intracellulare and was given clarithromycin, ethambutol, and rifabutin. The patient developed an acute change in mental status manifested by paranoid delusions, disorganized though processes, and perseverations which resolved after substitution of azithromycin for clarithromycin. Although the differential diagnosis of acute altered mental status in an AIDS patient is quite broad, we recommend that clinicians consider clarithromycin as a possible cause of psychosis and mania. Azithromycin should be considered as an alternative treatment in patients exhibiting such symptoms after initiation of clarithromycin.

Clinical Reasoning: An 8-year-old girl with multifocal brain lesions and cerebral edema

An 8-year-old right-handed girl with a history of declining school performance presented to the emergency center with acute onset altered mental status. For 3 weeks, the former straight A student had been failing classes, but her family noted no changes in her personality or ability to perform activities of daily living. On the night of presentation, the patient was found minimally responsive, lying in vomitus. She aroused briefly with stimulation but was limp. Her past medical history was significant for a full-term birth without complications, normal acquisition of developmental milestones, and no chronic medical conditions. She took no medications. She had no unusual food or animal exposures and had not traveled overseas. Her family had no history of seizures, strokes, blood clots, cancer, rheumatologic disorders, or recurrent miscarriages. On examination, she was afebrile with normal vital signs. Her examination was significant only for lethargy and bilateral papilledema. Initial workup revealed a normal complete blood count, electrolytes, and blood glucose. ### Question for consideration: 1. What is the most appropriate next diagnostic study? GO TO SECTION 2 An emergent CT of the …

Methadone and "Bath Salt" Use Causing Near-Fatal Posterior Reversible Encephalopathy Syndrome (P06.259)

Objective: To report previously unreported etiologies of PRES including methadone and bath salt use, resulting in near fatal complications. Background Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by headache, variable mental status, seizure, visual disturbances, and typical transient changes in the posterior cerebral perfusion. Its pathophysiology remains controversial, however it may be secondary to toxin induce endothelial dysfunction or relative hypertension causing imbalanced Starlin9s forces. The advent of modern brain imaging has afforded an improved understanding with well defined etiologies and presentations, but many atypical presentations exist. While typically associated with a benign prognosis, we present two patients with near fatal PRES related to the street drugs bath salt and methadone. Design/Methods: Case report from a tertiary medical center. Results: Patient 1: 26 year old male presented with acute altered mental status secondary to methadone overdose. Six days after admission patient noted to have new onset seizure, worsening mental status and imaging consistent with PRES. He was treated with anti-epileptics and supportive care. Two days later patient developed signs of brain stem herniation and further imaging revealed uncal and tonsillar herniation with Duvet9s haemorrhages. Patient 2: 51 year old male presented comatose after use of “Bath Salts” a legal drug of abuse with mixed hallucinogenic, agitative and sympathomimetic properties. Imaging confirmed PRES and course was complicated by hydrocephalus requiring extra ventricular drain placement and aggressive ICP management Conclusions: PRES is generally thought to be a benign, transient manifestation of encephalopathy resulting from reversible insult to the blood brain barrier in the setting of toxin, systemic illness, or hypertension with well defined etiologies. However, the cases presented here highlight atypical etiologies, methadone and bath salt use, resulting in near fatal complications. Disclosure: Dr. Pandya has nothing to disclose. Dr. Malaiyandi has nothing to disclose. Dr. Asi has nothing to disclose. Dr. Helms has nothing to disclose. Dr. Lynch has nothing to disclose.