Altered Mental Status Research Articles

October 2023 Critical Care Case of the Month: Multi-Drug Resistant K. pneumoniae

No abstract available. Article truncated after 150 words. History of Present Illness: A 75-year-old man presented from a skilled nursing facility with altered mental status and hypotension. He had a seven-year-long history of steroid-dependent myasthenia gravis, but had previously declined Covid vaccination, and subsequently experienced a severe case of COVID-19 pneumonia five months prior to admission. This resulted in chronic respiratory failure and renal failure for which he subsequently underwent tracheostomy, tunneled subclavian vein dialysis catheter placement and percutaneous endoscopic gastrostomy (PEG). He had resided in a skilled nursing facility since then, requiring four subsequent hospital readmissions for complications. These sequentially included septic shock due to a catheter associated blood stream infection, an intra-abdominal abscess due to PEG migration into the peritoneum resulting in fungal blood stream infection, recurrent intra-abdominal infection with multiple organisms, and bacterial pneumonia. Treatment of these infectious complications included replacement of the tunneled dialysis catheter and exploratory laparotomy with debridement of multiple abscesses. The …

정신과에 협진 의뢰된 입원 환자에서의 베르니케뇌병증 예측을 위한 의사 결정 모델 개발

Objectives: To determine predictive factors associated with the onset of Wernicke encephalopathy (WE) and produce a decision tree predicting patients prone to developing WE.
 Methods: Demographic, clinical, and laboratory data and the consultation notes of 314 inpatient alcohol use disorder consultation cases were collected. Receiver operative characteristic curve analysis was performed to identify the predictors of WE development.
 Results: Of the patients with alcohol use disorder, 34.08% developed WE, and 43.93% of those were also diagnosed with hepatic encephalopathy. Delirium history was a predictive factor for patients with alcohol use disorder, with the highest statistical significance, and 54.8% of the patients with prior delirium history developed WE. Hemoglobin (Hb) levels <12.1 g/dL and alanine aminotransferase (PT) levels ≥25 IU/L were the next most significant predictive factors. For patients with alcohol use disorder with altered mental status, a Hb level of 14.4 g/dL was a predictive factor with the highest statistical significance, and 73.3% of patients with Hb levels <14.4 g/dL developed WE. Total bilirubin levels ≥1.1 mg/dL and C-reactive protein (CRP) ≥2.6 mg/dL were the next most significant predictive factors.
 Conclusion: Assessing delirium history, Hb, and PT levels in patients with alcohol use disorder and Hb, total bilirubin, and CRP levels in patients with alcohol use disorder with altered mental status can help to evaluate the risk of developing WE.

Myxedema Coma: A Rare Case Report of Severe Hypothyroidism in Uganda

Objective: in this report, we describe a case of myxedema coma in a 46-year-old Ugandan lady who had never before had hypothyroidism. Investigations and Medical Care: The patient's first presentation included bradycardia, hypothermia, and a noticeably low Glasgow Coma Scale score. Laboratory examinations revealed severe primary hypothyroidism. Intravenous levothyroxine, hydrocortisone, and supportive care were the first steps in the treatment. Results: After receiving therapy for one week, the patient achieved a full recovery. Thyroid function tests showed improvement back to normal range. Conclusion: This case highlights the importance of considering myxedema coma in the differential diagnosis of altered mental status, even in resource-limited settings. Increased awareness, prompt diagnosis, and appropriate treatment can be life-saving in these cases.

Unusual case of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis

Metformin-associated lactic acidosis (MALA) and euglycaemic diabetic ketoacidosis (EKA) are both life-threatening endocrine emergencies. MALA is a well-documented complication of anti-glycaemic therapy in diabetics while EKA is an increasingly recognized disease entity with the advent of use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. However, the occurrence of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis (MALKA) is uncommon and rarely reported in the literature. We report an unusual case of MALKA, in a 74-year-old gentleman with no previous history of chronic kidney disease and SGLT-2 inhibitor use, who presented with altered mental status, acute renal failure and profound high anion-gap metabolic acidosis (HAGMA) with lactaemia, ketonaemia and normoglycaemia (pH 6.965, bicarbonate 3.1, creatinine 522, glucose 6.6, lactate 17.5, ketones >8). The patient was initiated on intravenous insulin infusion with dextrose-containing drip and continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The patient had a prolonged hospital stay but was eventually discharged with a normalised renal function without need for long-term dialysis. The parallel occurrence of MALA and EKA suggest a metformin-associated inhibition of gluconeogenesis. This case highlights the importance of early recognition and investigation of concurrent diabetic ketoacidosis in the presence of MALA and vice versa as MALKA benefits from both prompt institution of parenteral glucose therapy and insulin infusion and consideration of initiation of haemodialysis.

Integrating Neuromonitoring in Pediatric Emergency Medicine: Exploring Two Options for Point-of-Care Electroencephalogram (pocEEG) via Patient Monitors-A Technical Note.

Central nervous system (CNS) disorders are among the most frequent presentations in critically ill children. Status epilepticus (SE) is a frequent scenario in the resuscitation bay. In patients with altered mental status, non-convulsive SE (NCSE) is often underrecognized and critically impacts the neurological outcome and duration of hospitalization. An electroencephalogram (EEG) is required to diagnose NCSE. However, standard EEG recordings are time- and staff-intensive, and their availability is limited, especially outside regular working hours. We aimed to improve patient care by developing a simplified EEG recording method, using a reduced lead montage (point-of-care EEG-pocEEG), that is suitable for use in pediatric emergency departments. The objective was to devise a cost-effective unit with low space requirements that fitted the existing technical infrastructure. We present two technical options for clinical pocEEG acquisition using patient monitors (GE Carescape, Philips IntelliVue) that enable data collection for educational and research purposes. A simplified, rapid response EEG like the pocEEG enables neuromonitoring of patients with CNS disorders in pediatric emergency settings, facilitating timely diagnosis and treatment initiation when standard EEG is not readily available.

Mortality Risk Scoring System in Patients after Bleeding from Cancers in the Upper Gastrointestinal Tract.

: Risk scoring systems for upper gastrointestinal (UGI) bleeding have not been well validated for tumor bleeding. This study aimed to identify risk factors for mortality in patients with UGI cancer bleeding and to develop a predictive model. : Consecutive patients with UGI cancers who underwent esophagogastroduodenoscopy for suspected bleeding were retrospectively included. Patient characteristics, endoscopic findings and 30-day mortality were assessed. A predictive model was made based on risk factors for mortality using logistic regression, and the area under the curve (AUC) of this model was calculated. It was then compared with other risk scoring systems. : In a total of 264 patients, 193 had tumor bleeding. Among them, 108 (56.0%), 76 (39.4%), and nine (4.7%) patients received conservative treatment, endoscopic therapy, and non-endoscopic hemostasis, respectively. Rebleeding occurred in 23 (21.3%), 26 (34.2%), and one (11.1%) patient(s), respectively. Our new model is composed of altered mental status, renal failure, rebleeding, age older than 65 years, and low serum albumin (all p<0.05). This model predicted 30-day mortality with an AUC of 0.79 (95% confidence interval, 0.72 to 0.86), which was significantly higher than AUCs of the Glasgow-Blatchford score, Rockall, and AIMS65 score (AUC=0.61, 0.64, and 0.69, respectively, all p<0.05). : Our new scoring system provides a better prediction of 30-day mortality than existing scoring systems in patients with UGI cancer bleeding. This new scoring system can be used to predict and prepare these patients who are known to have high mortality.

Treatment variability and its relationships to outcomes among patients with Wernicke's encephalopathy: A multicenter retrospective study

BackgroundDespite guidelines and recommendations, Wernicke's encephalopathy (WE) treatment lacks evidence, leading to clinical practice variability. AimsGiven the overall lack of information on thiamine use for WE treatment, we analyzed data from a large, well-characterized multicenter sample of patients with WE, examining thiamine dosages; factors associated with the use of different doses, frequencies, and routes; and the influence of differences in thiamine treatment on the outcome. MethodsThis retrospective study was conducted with data from 443 patients from 21 centers obtained from a nationwide registry of the Spanish Society of Internal Medicine (from 2000 to 2012). Discharge codes and Caine criteria were applied for WE diagnosis, and treatment-related (thiamine dosage, frequency, and route of administration) demographic, clinical, and outcome variables were analyzed. ResultsWe found marked variability in WE treatment and a low rate of high-dose intravenous thiamine administration. Seventy-eight patients out of 373 (20.9%) received > 300mg/day of thiamine as initial dose. Patients fulfilling the Caine criteria or presenting with the classic WE triad more frequently received parenteral treatment. Delayed diagnosis (after 24h hospitalization), the fulfillment of more than two Caine criteria at diagnosis, mental status alterations, and folic acid deficiency were associated significantly with the lack of complete recovery. Malnutrition, reduced consciousness, folic acid deficiency, and the lack of timely thiamine treatment were risk factors for mortality. ConclusionsOur results clearly show extreme variability in thiamine dosages and routes used in the management of WE. Measures should be implemented to ensure adherence to current guidelines and to correct potential nutritional deficits in patients with alcohol use disorders or other risk factors for WE.

Clinical presentations and microbiological analysis of cerebrospinal fluid samples in cases of suspected bacterial meningitis patients attending a 1600 bedded teaching hospital from 2019 to 2022: A retrospective study.

Meningitis can be attributed to bacterial, fungal, or viral agents. In this study, we demonstrate the common bacterial agents causing meningitis along with their antibiotics susceptibility pattern in patients of all age groups. This retrospective, observational study was carried out in the Department of Microbiology with cerebrospinal fluid (CSF) samples collected from November 2019 to May 2022. We collected 1986 nonrepeat CSF samples from clinically suspected patients of bacterial meningitis, and clinical information about the patients was extracted from the hospital information system. Out of the 1986 CSF samples included in our study, 150 (7.55%) were found to be positive on bacterial culture. Most of our patients were in the age group of 0-20 years. Common clinical manifestations observed in our patients were: high-grade fever, 87 patients (58%); severe headache, 126 patients (84%); neck rigidity, 47 patients (31.3%); altered mental status, 76 patients (50.7%) and photophobia, 83 patients (55.3%). The most commonly isolated bacteria was Acinetobacter species (30%). The mean length of hospitalization (37.76 ± 25.30), the mean total cell count, high levels of protein (mg/dl) and low levels of glucose (mg/dl) of CSF were statistically significant in meningitis caused by multidrug-resistant bacteria. We recognized the spectrum of pathogens causing meningitis at our center along with the antibiotic resistance pattern to guide and facilitate early treatment by primary health care professionals and family medicine practitioners.

Knowing Your Target: Altered Mental Status From an Unsuspected Source

Daratumumab is a human monoclonal antibody targeting CD38 that is used in the treatment of multiple myeloma. In addition to being a target for cancer-related treatment, CD38 also plays a significant role in the immune response to infection. CD38 deficiency can increase susceptibility to several bacterial infections. This article discusses the case of a 52-year-old female with a history of IgG multiple myeloma status post autologous stem cell transplant with relapse who was receiving therapy with daratumumab, lenalidomide, and dexamethasone. She presented to the emergency department with a history of 3 to 4 days of generalized weakness, poor appetite, nausea, vomiting, watery stools, and fevers. Her symptoms did not improve with initial fluid resuscitation and broad-spectrum antimicrobials; instead, she experienced progressive neurological decline. This case illustrates how utilizing targets for cancer-directed treatments can also affect immune function, which may leave patients susceptible to unique infections that may not otherwise be commonly encountered. Therefore, advanced practitioners must understand the functional role of these targets and the sequelae that could occur when expression is altered by pharmacological therapies to allow for expeditious recognition and management.

Dengue Causing Posterior Reversible Encephalopathy Syndrome: A Case Report from India

Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by altered mental status, headaches, visual disturbances, and seizures and caused due edema affecting mainly the parietal and occipital lobes of the brain. This clinical entity is increasingly established due to improvements in radiological investigations. Patient’s Concern: We present a 22-year-old female with 9-month amenorrhea with altered sensorium; the noncontrast computed tomography head showed ill-defined hypodensities in the bilateral occipital and parietal region suggestive of the PRES. Intervention: The patient was managed immediately with an injection of levetiracetam with intravenous (IV) fluids, antibiotics, and IV steroids. The patient had gross improvement in the sensorium and vision within 24 h. The patient was discharged on the 10th day of admission with 100% recovery. Follow-ups at 2 and 4 weeks were uneventful. Lesson Learnt: Even dengue can cause PRES, so the clinical entity should be recognized as early as possible. The treatment should be initiated urgently; knowledge of this can easily prevent unnecessary morbidity and mortality with complete recovery.

Clinical Features of Cryptococcal Meningoencephalitis in HIV-Positive and -Negative Patients in a Resource-Limited Setting.

Cryptococcal meningoencephalitis is a systemic fungal infection in immunocompromised and immunocompetent individuals. This study investigated the clinical characteristics and factors associated with mortality in HIV-associated and non-HIV-associated cryptococcal meningoencephalitis in a resource-limited setting. This was a retrospective cohort study of patients with cryptococcal meningoencephalitis between January 2009 and December 2019 at a tertiary teaching hospital in Thailand. Overall, 1019 patients with cryptococcal meningoencephalitis were enrolled, and 923 (90.6%) were HIV-positive. The patients with HIV-associated cryptococcal meningoencephalitis were younger than the HIV-negative patients (37 versus 56 years, p < 0.01). The HIV-negative patients were more likely to have underlying conditions (52.1% versus 7.5%; p < 0.01), had a longer median duration of headaches prior to admission (14 days versus 6 days, p < 0.01), and were more likely to have an altered mental status at presentation (36.5% versus 18.6%, p < 0.01) and pulmonary involvement (15.6% versus 0.8%, p < 0.01). The HIV-positive patients had lower cerebrospinal fluid (CSF) white blood cell counts (4 versus 94 cells/mm3; p < 0.01), lower CSF protein (69 versus 157 mg/dL; p < 0.01), higher CSF glucose (38.8 versus 21 mg/dL; p < 0.01), and more frequent cryptococcemia (44.1% versus 20.5%; p < 0.01). The mortality rate was high but not significantly different between the two groups (30.2% versus 33.2%; p = 0.53). The HIV-positive patients with comorbidities, fever, an altered mental status at presentation, a CSF white blood cell count below 20 cell/mm3, fungemia, and positive CSF India ink were independently associated with 30-day mortality. In comparison, an altered mental status at presentation and fungemia were associated with 30-day mortality in HIV-negative patients. In conclusion, HIV-negative patients with cryptococcal meningoencephalitis had more extensive central nervous system inflammation, although the two groups' mortality rates were similar. Unfavorable prognostic factors included comorbidities, fever, an altered mental status at presentation, a low CSF white blood cell count, fungemia, and positive CSF India ink.

Risk Stratification in Egyptian Patients with Upper Gastro Intestinal Bleeding

Abstract Introduction Acute upper gastrointestinal bleeding is a common and life-threatening condition. It remains a common cause of visits to the emergency department with an estimated incidence of about 100 per 100000 hospitalizations and being associated with significant morbidity, 30 day mortality and health-care costs. Urgent triage in emergency departments and risk stratification can help to identify patients who warrant urgent diagnostic and therapeutic procedures. We aimed to assess the correlation between Glasgow-Blatchford Bleeding Score, the AIMS65 score and Rockall score in sixty Egyptian patients with upper gastrointestinal bleeding, and to evaluate the best scoring system for risk stratification in these patients. Methods This prospective study included 60 Egyptian patients presented to Ain shams university hospital with upper gastrointestinal bleeding. All patients underwent emergency endoscopic evaluation within 12 hours of presentation. Surgical and radiological interventions were considered for patients who failed or were not feasible for endoscopic therapy. Rockall score, Glascow-Blatchford and AIMS65 were calculated for each patient. Results the age of the studied patients ranging between 20 and 81 years old with a mean age of 55.57 ± 13.14, of them 66.7% were males and 33.3% were females. Most of the patients (90%) had co-morbidities in the form of hepato-billiary diseases (70%), HTN (30%), DM (26.7%), cardiac disease (8.3%), and GIT related disorders (6.7%). Portal hypertension gastropathy was the most common finding in UGIT endoscopy (58.3%) followed by esophageal varcies (56.7%), then gastritis (30%), then peptic ulcer (20%) and lastly gastric mass (6.7%). Rockall score had significant association with altered mental status and liver cirrhosis. Rockall score was found to be the most effective predictor for mortality (sensitivity 100%, specificity 67.92% and AUC 91.0%). Conclusion complete Rockall score is the most effective scoring system for prediction of in hospital mortality in patients with upper gastrointestinal bleeding.

Elevated Osmolal Gap in a Case of Multiple Myeloma

BackgroundThe estimated serum osmolality is a measurement of solutes in the blood, including sodium, glucose, and urea, but also includes ethanol and toxic alcohols (e.g., methanol, ethylene glycol, diethylene glycol, isopropyl alcohol, propylene glycol) when present. These rarely measured toxic alcohols can elevate the serum osmolality, giving the true measured osmolality. The difference between that and a calculated osmolality is the osmolal gap, which can be elevated in many clinical scenarios such as renal failure, ingestion of toxic alcohols, diabetic ketoacidosis, shock, and others. Case ReportWe report a patient with a history of alcohol use disorder who came to the Emergency Department with an abnormally elevated osmolal gap in the setting of altered mental status. The patient's increased osmolal gap was further investigated while he was promptly treated with fomepizole, thiamine, and urgent hemodialysis. Why Should an Emergency Physician Be Aware of This?We discuss the differential diagnosis for substances that increase the osmolal gap with respective ranges of elevation. This case demonstrates that although osmolal gap elevation is often attributed to the presence of toxic alcohols, other common etiologies may account for the gap, including acute renal failure and multiple myeloma.

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions. We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits. It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

Stress in Acute Coronary Syndrome: A Cross-sectional Study in Kelantan and Terengganu, Malaysia

Background: Stress often happens in acute coronary syndrome (ACS) patients, especially during hospitalization. Objectives: The current study intended to identify the prevalence of stress and its associated factors among ACS patients in two selected hospitals in Kelantan and Terengganu, Malaysia. Methods: A total of 400 ACS patients in both hospitals participated in this cross-sectional study. Acute coronary syndrome patients above the age 18 years old, can read, speak and understand in Malay language and were obtained informed consent were included in the study. The study excluded those patients who were intubated, had any altered mental status, were mentally retarded, and had psychological problems. Stress among ACS patients was measured using the validated questionnaire of the Malay version of the Depression Anxiety Stress Scale 21. Logistic regression was used for analysis. Results: Of these ACS patients, 58.5% had stress symptoms. A higher frequency of stress was found in patients of male (63.7%), Malay (82.1%), and married (67.1%). Acute coronary syndrome patients with comorbid of ischemic heart disease were a strong and independent factor associated with stress (adjusted odds ratio: 1.73, 95% confidence interval: 1.14 - 2.63, P = 0.010). Conclusions: The prevalence of stress in the study population was high and significantly associated with comorbid of ischemic heart disease. Creating awareness regarding the risk factors of stress is recommended. In addition, policies should be implemented to reduce the risk of stress among patients.

Excited delirium syndrome

Mental health calls make up a large proportion of ambulance workloads, with paramedics responding to a wide range of presentations such as anxiety, depression, bipolar disorder, schizophrenia, and excited delirium syndrome. Excited delirium syndrome is an increasingly common presentation, characterised by extreme agitation and aggression in a patient with an altered mental status. Excited delirium is a potentially life-threatening condition, with generally non-specific symptoms. Common triggers of excited delirium syndrome are acute drug use, psychiatric illness, or abrupt cessation of antipsychotic medication. It occurs when there is excessive dopamine stimulation in the striatum, combined with acute exposure to catecholaminergic psychoactive substances. A history of schizophrenia, or bipolar disorder are known risk factors for excited delirium syndrome. While agitation and aggression, concomitant with an altered mental status are the hallmark of excited delirium, other medical conditions such as hypoxia, head trauma, hypoglycaemia, hyperglycaemia, and infection can produce similar symptoms, and need to be ruled out as causes. Safety is paramount in the management of excited delirium, with the use of physical and chemical restraint being commonplace. Rhabdomyolysis often occurs when the patient is able to exercise extreme exertion against the restraints and this should be minimised to prevent the risk of cardiac arrest.

Factors associated with violence against nursing students at the rotary internship

Introduction: violence is a public health problem, among which we find workplace violence, which is identified when a worker suffers abuse, threats, and attacks that can be verbal and physical. Rotating internship nursing students play an important role within healthcare institutions.Objective: to determine the factors associated with violence against nursing students in the rotating boarding school.Methods: the study presents a non-experimental research design with a quantitative, descriptive, and cross-sectional approach in a group of nursing students of the rotating internship, with a sample of 121 participants, to whom a questionnaire with a reliability of 0.717 of Alpha Cronbach was applied.Results: a low risk was reported about violence by the patient's family member with 88,43 %, although a small group of students is at medium risk with 11,57 %. As for the factors associated with violence, medium and high risk is shown at 56,2 %.Conclusions: nursing interns receive many physical, verbal, and psychological aggressions at work from relatives of patients and colleagues with higher hierarchies. In the current study, it was possible to observe the presence of blows in physical violence, humiliation, and rudeness in psychological violence and the individual associated factors of aggression by the immediate superior boss, by aggressors in altered mental state, and aggressors by the state of health of the relatives

Comparative performance of microbiological methods for the detection of tuberculous meningitis pathogens in cerebrospinal fluid

The aim of this study was to comprehensively evaluate metagenomic next-generation sequencing (mNGS), Acid-fast bacillus stain (AFB), MGIT960 culture, polymerase-chain-reaction (PCR), and Xpert MTB/RIF in the diagnosis of tuberculous meningitis (TBM). A cohort of 280 patients who presented with suspected TBM (ie, headache or altered mental status with clinical signs of meningism) were analyzed. The sensitivities of the 5 assays for the diagnosis of TBM ranged from 10.0% to 70.0%. The AFB had the lowest sensitivity of 10.0% (0.5-45.9), while mNGS and PCR had the highest sensitivity, both at 70.0% (35.4-91.9). mNGS demonstrated a distinct advantage in identifying a wider array of pathogens, including viruses, in CSF samples. PCR was a cost-effective option with excellent sensitivity and specificity. However, no single method was statistically significantly better than any other in the diagnosis of TBM. New diagnostic techniques are urgently needed for the independent, rapid and accurate detection of Mycobacterium tuberculosis to guide the diagnosis of TBM.

First Case of Meningoencephalitis and Bacteraemia with Flavobacterium Lindanitolerans.

Flavobacterium lindanitolerans is an environmental Gram-negative, non-spore-forming rod which is usually not considered to be a human pathogen. Isolation from human clinical samples has been described only once. We report the first case of meningoencephalitis and bacteraemia with Flavobacterium lindanitolerans. A 76-year-old female presented with fever, headache, alteration of mental status, marked meningism and dysarthria. A lumbar puncture demonstrated cerebrospinal fluid findings consistent with bacterial meningitis, and a broad-spectrum antibiotic therapy was initiated. Blood and cerebrospinal fluid cultures revealed a growth of Flavobacterium lindanitolerans. Based on antimicrobial susceptibilities testing, antibiotic treatment was changed to levofloxacin, resulting in a remission of the clinical symptoms after 21 days of treatment. Flavobacterium species are extremely rare human pathogens. However, some of them have been reported to cause opportunistic infections. We describe the first case of meningoencephalitis and bacteraemia caused by Flavobacterium lindanitolerans which was effectively treated with levofloxacin for 21 days. This is the first case of a meningoencephalitis and bacteraemia with Flavobacterium lindanitolerans.Levofloxacin can be given for 21 days as a treatment of F. lindanitolerans.

Recurrent Spontaneous Intracranial Hypotension (SIH) and the Durability of Repeat Epidural Blood Patch (EBP).

Spontaneous intracranial hypotension (SIH) remains a rare and difficult clinical entity to diagnose and treat. Epidural blood patch (EBP) of the dural sac is the mainstay definitive treatment for refractory cases and has mixed efficacy. We sought to evaluate the recent efficacy and outcomes of EBP for SIH at our institution. Twenty-three patients (14 women, 9 men, mean age 49) were seen and treated for SIH between Summer 2009 and Spring 2018 at the same institution. All patients underwent brain MRI with and without gadolinium contrast and T2-weighted spine MRI.Targeted EBP was placed one or two vertebral levels below areas of suspected leak, while the patient was positioned in the lateral decubitus position. Patients were seen in the outpatient setting within a week following initial EBP and repeat EBP was offered to patients with persistent symptoms. Patients were followed if symptoms persisted or for 6 months following clinical relief of symptoms. 22/23 (95.7%) patients presented with complaints of orthostatic headache, and 3 (13%) patients presented with altered mental status (AMS) or focal neurologic deficit. Brain MRI demonstrated pachymeningeal enhancement in 16/23 (69.6%) patients, and 5/23 (21.7%) patients had a subdural hematoma (SDH) present. Dural leaks were successfully identified in 18/23 (78.3%) patients. 12/23 (52.2%) patients had symptomatic relief with initial EBP, and 5/23 (21.7%) patients received further EBPs for persistent disease with all achieving relief after repeat EBP. 5/12 (41.7%) of patients had recurrent symptoms after initial relief with EBP, and 4/5 (80%) were successfully treated with a second EBP. The mean initial EBP volume and number of EBPs per patient were 21.7 mL (median 20 mL, 7-40 mL) and 3.54 (median 1, 1-13) respectively. There was one complication from initial EBP (cervical dural tear requiring operative closure) treated with open surgical management successfully. In total, 18/23 (78.2%) patients are currently asymptomatic with regard to their SIH. The mean follow-up in this cohort was 2.6 years (median 1.8 years, 1.8 months-9.27 years). EBP is a viable and effective option for the treatment of recurrent SIH caused by cerebrospinal fluid (CSF) leaks.