Altered Mentation Research Articles

Ethanol toxicity in a dog due to gin‐soaked sloe berry (Prunus spinosa) ingestion

AbstractA 10‐month‐old male Labrador retriever was presented for acute onset altered mentation and inability to walk. The dog was presented with a modified glasgow coma scale (MGCS) of 12 with tachycardia (148 bpm) and hypothermia (37°C). The dog had been normal the previous night then found semi‐comatose at the following morning. Investigations included haematology, biochemistry, C‐reactive protein, magnetic resonance imaging, urine toxicology and cerebrospinal fluid analysis. Ten hours after being found the dog passed faeces containing a significant volume of berries. The owner later determined that 750 g of sloe berries soaked in gin were missing from the garden compost heap. Serum ethanol concentrations measured approximately 20 hours after the suspected consumption were 310 mgD/L. The dog was treated with intralipid, intravenous fluid therapy and paracetamol. He was neurologically normal (MGCS = 0) 24 hours later, following diagnosis and treatment. Differential diagnosis and management of the comatose dog and management of ethanol toxicity are discussed.

Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19.

ObjectiveSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality.MethodsA total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death.ResultsA total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04–1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65–5.92) had a higher risk of mortality than age- and severity-matched controls.ConclusionsThe incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.

Clinical Characteristics and Treatment Outcomes of De Novo Nonconvulsive Status Epilepticus: A Retrospective Study.

Background and PurposeNonconvulsive status epilepticus (NCSE) is challenging to diagnose. This study aimed to describe and classify the clinical features and electroencephalography (EEG) findings of patients with de novo NCSE and to correlate them with clinical outcomes.MethodsWe retrospectively reviewed the medical and EEG records of patients admitted to our institution with altered mentation and EEG abnormalities from January 1, 2013 to December 31, 2018. We evaluated premorbid modified Rankin Scale (mRS) scores, underlying disorders, precipitating factors, clinical manifestations, laboratory tests, and outcomes after a 3-month follow-up. Patients who met the Salzburg Consensus Criteria for NCSE were categorized into good-outcome and poor-outcome groups. A good outcome was defined as 1) clinical and electrographic seizures ceasing after treatment, and 2) an mRS score of ≤2 or remaining unchanged during the 3-month follow-up. A poor outcome was defined as 1) death, 2) seizures continuing despite treatment, or 3) a follow-up mRS score of ≥3 in a patient with a premorbid mRS score of ≤2, or a follow-up mRS score that increased in a patient with a premorbid mRS score of ≥3.ResultsThe 48 included patients comprised 37 categorized into the good-outcome group and 11 into the poor-outcome group. The presence of acute metabolic disturbances was significantly correlated with poor outcome (p=0.036), while the other analyzed variables were not significantly correlated with outcomes.ConclusionsAcute metabolic disturbances in NCSE are associated with poor outcomes. Adequate treatment of underlying reversible disorders alongside controlling seizures is critical for patients with NCSE.

A retrospective evaluation of eastern coral snake envenomation and antivenom administration in cats: 30 cases (2012–2019)

Thirty cats were identified to be have been suspected to have a potential coral snake envenomation after searching medical records from 2012 to 2019 at a university teaching hospital. The records were reviewed and evaluated for signalment, date and time of the snake encounter, elapsed time between encounter and hospital examination, presenting complaint, initial physical examination findings, initial laboratory findings, antivenom dose and duration of administration, adverse reactions to antivenom, additional treatments administered, progression of clinical signs, length of hospitalization, and outcome. Thirteen cats presented with clinical signs consistent with envenomation while 17 cats were treated for possible asymptomatic envenomation, as defined by the owner discovering a live or dead coral snake in their home or on their property. Initial physical examination findings included tachypnea with short shallow breaths and use of accessory muscles; tetraparesis with normal or decreased to absent spinal reflexes; cranial nerve deficits including decreased to absent gag, slow pupillary light reflexes, and absent physiologic nystagmus; and normal or altered mentation. Laboratory findings included hypercapnia, hyperglycemia, hypokalemia, increased aspartate aminotransferase activity, increased alanine aminotransferase activity, echinocytosis, leukocytosis, azotemia, and hyperlactatemia. Twenty-eight cats received antivenom; two cats received two vials while twenty-six cats received one vial. Antivenom reaction was suspected in one cat that developed facial swelling during administration of the drug. Average length of hospitalization was 1 day for cats without clinical signs and 3 days for cats with clinical signs. Twenty-nine cats survived to discharge. Due to the inclusion criteria of the study, cats euthanized on presentation or discharged without receiving antivenom may have been unintentionally excluded from the study.Diagnosis of eastern coral snake envenomation should be suspected in the cat that has acute onset of lower motor neuron neuropathy. Prognosis with treatment is considered good with 97% of cats surviving to discharge. Antivenom reaction occurred in 3.5% of administrations with none being fatal. Monitoring of hypercapnia was critical in making the decision to mechanically ventilate patients. Supportive care that includes antivenom administration, recumbency care, and mechanical ventilation if needed are the mainstays of therapy.

Brain Injury in Critical Illness and a Note on the Virus

Brain Injury in Critical Illness and a Note on the Virus

MARIJUANA-INDUCED HYPERTENSION: A 'PRES'-ING MATTER

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic condition of varied etiologies which typically involves the white matter of the posterior cerebral hemispheres. Posterior circulation vasogenic edema is seen on MRI. Although the full extent of PRES is not well understood, patients of all age groups have been affected. Features include hypertension, seizures, and altered consciousness. It is prudent to consider PRES in stroke patients who present with vision abnormalities and altered mentation. We present a case with symptoms of PRES in the setting of marijuana induced hypertensive encephalopathy. CASE PRESENTATION: A 41-year-old male with history of previous CVA, seizures, hypertension, and polysubstance abuse presented after being found with altered mentation. The patient remained agitated despite receiving sedatives, required mechanical ventilation for airway protection. His BP was 180/104. He is a chronic cannabis user. The patient’s previous CVA, 5 years ago, resulted after CO poisoning and hypertensive emergency with subsequent encephalopathy. MRI at that time showed acute infarcts involving b/l occipital, temporal, parietal lobes, & thalami resulting in posterior CVA/cortical blindness, with development of seizures. MRA demonstrated vertebral artery dissection. MRI on admission revealed development of subcortical white matter signal changes in the parieto-occipital and frontal white matter. These findings are suggestive of PRES in this hypertensive patient, suggesting that this is an unusual presentation of the consequences of his chronic THC use causing hypertensive encephalopathy with recurrent PRES. DISCUSSION: There are various pathogeneses for development of PRES. Our patient’s presentation 5 years ago suggests that there was a component of both hypertension and hypoperfusion from ischemic stroke. Normal autoregulation preserves cerebral blood flow through arteriolar constriction/dilatation. As BP increases, cerebral arterioles dilate causing increased cerebral blood flow and brain hyperperfusion causing breakdown of the blood-brain-barrier permitting extravasation of blood products into brain parenchyma. This vasogenic edema contributes to symptoms of PRES. His current presentation is more due to hypertension, believed to be marijuana induced. CVS effects of marijuana are tachycardia, hypertension, increased levels of carboxyhemoglobin. Cannabinoids bind to cannabinoid receptors, CB1-CNS and CB2-immune system. There are few cases of cannabis induced ischemic stroke & hypertensive encephalopathy associated PRES. It is important to highlight that marijuana can result in systemic complications. CONCLUSIONS: Although called posterior reversible encephalopathy syndrome, it is not always reversible. PRES should be considered in patients presenting similarly to evaluate with appropriate imaging and begin treatment based on the comorbidities of the patient. Reference #1: Qiang Zhang, George Richerson, Nandakumar Narayanan Neurology Apr 2017, 88 (16 Supplement) P4.066 Reference #2: Uhegwu N, Bashir A, Hussain M, Dababneh H, Misthal S, Cohen-Gadol A. Marijuana induced Reversible Cerebral Vasoconstriction Syndrome. J Vasc Interv Neurol. 2015;8(1):36-38. DISCLOSURES: No relevant relationships by Laith Al-janabi, source=Web Response No relevant relationships by Saad Chaudhry, source=Web Response No relevant relationships by Yashar Eshman, source=Web Response No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response

S1472 Some People Get Stoned Over and Over Again: A Case Report on Recurrent Pyogenic Cholangitis

INTRODUCTION: Recurrent pyogenic cholangitis (RPC) is a disease predominantly found in Asian patients. It is the result of biliary stasis and stone formation in the proximal biliary tree due to strictures resulting in intrahepatic ductal dilatation, contrary to typical western biliary obstruction presentation. CASE DESCRIPTION/METHODS: A 79-year-old lady, immigrant from China, presented to the emergency department with altered mentation, jaundice, and abdominal pain. Patient has a pertinent history of cirrhosis, chronic hepatitis B, and numerous prior admissions for choledocholithiasis and ascending cholangitis over a period of eight years requiring multiple endoscopic retrograde cholangio-pancreatography (ERCP) procedures and common bile duct (CBD) stenting. On presentation, she was febrile, hypotensive, and tachycardic with right upper quadrant tenderness. Labs demonstrated leukopenia, lactic acidosis, and direct bilirubinemia. CT scan of the abdomen (Figure 1) showed diffuse intrahepatic and extrahepatic biliary dilatation, which has progressed from prior imaging one year ago, and presence of two CBD stents inserted 2 months ago. The clinical picture was concerning for ascending cholangitis secondary to choledocholithiasis and stent malfunction. She was bolused with IV fluids, started on broad-spectrum antibiotics, and transferred to the intensive care unit. She was then taken for ERCP (Figure 2). Two stents were removed which was followed by passage of multiple stones of different sizes (Figure 3). The remainder of stones were removed with balloon sweep and a new stent was placed in CBD. Her presentation with numerous recurrent episodes of ascending cholangitis, biliary dilatation, and recurrent stone formation leads to the diagnosis of RPC. Patient was offered definitive treatment with interval cholecystectomy and choledochojejunostomy but she elected for non-surgical management. She continued to improve on antibiotic therapy and was eventually discharged home. DISCUSSION: RPC is a rare cause of ascending cholangitis in the US, typically seen in immigrants from Southeast Asia. The resulting stones are numerous and mainly composed of calcium bilirubinate. Patients get frequent exacerbations throughout their lives. Cirrhosis and portal hypertension can develop in severe cases. Acute management involves removal of the stones and management of secondary infections. Long term treatment involves regular surveillance or surgical hepatobiliary resection of affected area with biliary-enteric anastomosis.Figure 1.: CT abdomen with IV contrast showing (A): intrahepatic biliary dilatation, (B): distended gallbladder with cholelithiasis (asterisk) and CBD dilatation (arrow) up to 2.2 cm in diameter with two stents, (C): a coronal view of the hepatobiliary system and two stents extending from the proximal CBD to the duodenum.Figure 2.: ERCP fluoroscopy showing (A): significant extrahepatic biliary dilatation with filling defects (arrow) likely gallstones, (B): moderate intrahepatic biliary dilatation.Figure 3.: Endoscopic images from ERCP procedure showing (A): two CBD pigtail stents removal and exudative biliary drainage from the ampulla of Vater, (B): confluence of gallstones that passed into the duodenum after the extraction of the CBD stents.

S1505 Choledochoduodenal Fistula: An Old Complication of Choledocholithiasis With a New Presentation

INTRODUCTION: Enterobiliary fistulas were first described in 1654 with 68% of cases occurring between the gallbladder wall and duodenum. Choledochoduodenal fistulas (CDF) are less common (8.6%) and most are asymptomatic. This case highlights a rare presentation of pneumobilia, cholangitis, and pyogenic hepatic abscesses in a patient with CDF. CASE DESCRIPTION/METHODS: A 68 year old male with a past medical history of diabetes presented with rigors and fevers for one day. He denied abdominal pain, history of gallbladder disease, or recent travel history. Vitals signs were notable for BP 70/40, HR 110, T 101 F. Physical exam was remarkable for scleral icterus, but no abdominal tenderness or altered mentation. Lab results revealed WBC 31,000, creatinine 3.94, total bilirubin 9.6, direct bilirubin 7.9, AST 117, ALT 94, ALP 484, lactate 7.4, and positive blood cultures for Escherichia coli. CT abdomen without contrast revealed marked intra and extrahepatic bile duct dilatation with multiple focal densities identified in the liver and pneumobilia at the level of the distal common bile duct (CBD) (Figure 1). Antibiotics were started and he underwent ERCP which revealed a suprapapillary CDF with significant stone burden and pus in the CBD. Sphincterotomy was performed to the level of the CDF. Many stones were removed and two plastic stents were placed to ensure drainage. Follow up liver MRI revealed numerous hepatic abscesses. The patient’s vitals and laboratory markers improved with antibiotics, and he was scheduled for follow up outpatient ERCP to complete endotherapy. DISCUSSION: CDF can be caused by choledocholithiasis, duodenal ulcers, tumor invasion, or post-cholecystectomy complications. Most cases of CDF are asymptomatic and incidentally detected. However in the subset of symptomatic cases, cholangitis is the most common presentation. Furthermore, chronic cholangitis due to reflux of duodenal contents with bacterial flora may cause hepatic abscesses, though this has only been documented in case reports. Diagnosis can be achieved by ERCP with direct visualization of CDF and successful cholangiography through the papilla and fistula orifice. With few studies investigating this entity, proposed treatment options are conflicting. Some advocate for less invasive measures, such as endoscopic interventions for asymptomatic patients or distal CDF. Others regard CDF as a biliary abnormality that predisposes to recurrent infections and increases the risk for malignancy, and thus advocate for surgical management.Figure 1.: This sagittal view of a noncontrast CT abdomen/pelvis delineates hepatic abscesses, pneumobilia at the level of the choledochoduodenal fistula, and dilated intra and extrahepatic bile ducts.

COVID ENCEPHALOPATHY IN THE SETTING OF MULTIPLE BILATERAL ACUTE CEREBRAL VASCULAR INFARCTS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The SARS-CoV2 virus is well known for causing atypical pneumonia in addition to other symptoms. Various neurological symptoms have been reported including anosmia, headaches, and stroke like symptoms. Here we report a case of a critically ill patient who developed encephalopathy with evidence of multiple bilateral acute strokes. CASE PRESENTATION: 68-year-old African American male with no significant past medical history presented with shortness of breath, cough, and fever. He was tested positive for COVID-19. Patient quickly desaturated after admission requiring intubation and ICU care. During his hospital course, he developed severe renal injury which required hemodialysis. Despite daily dialysis in attempt to correct uremia and cessation of all sedations, patient remained minimally responsive. CT head without contrast was unremarkable for any acute process. Despite improvement in his respiratory status and azotemia, patient remained encephalopathic, unable to be extubated. He was subsequently treated empirically with Keppra for possible subclinical seizures and methylphenidate for neurostimulation, no improvement was seen. Due to the hospital protocol to limit exposure, our patient was one of the first in our hospital to receive a brain MRI after 29 days of hospitalization, which revealed numerous small areas of restricted diffusion throughout the centrum semiovale bilaterally compatible with extensive small acute infarct. There was also an acute infarct adjacent to the frontal horn. Based on the locations of the infarcts, they were determined to be most likely ischemic in nature. The patient remained intubated in the ICU with guarded prognosis without improvement in his status, he later entered hospice care as per family’s wishes. DISCUSSION: The neurological manifestations of SARS-CoV2 virus vary. According to a series of 13 cases studied showed 2 of 13 patients with brain MRI had single acute ischemic strokes. (3) Our case showed multiple bilateral infarcts on MRI, which has scarcely been reported. It was concluded that his encephalopathy was related to these cerebral infarcts. The varied coagulopathy features seen in COVID patients is well known and cases of microthrombi have been reported. Our patient was given full dose anticoagulation after admission but, altered mentation made extubating impossible. CONCLUSIONS: Our patient was able to fight COVID pneumonia but incurred extra pulmonary consequences. This presentation emphasizes early MRI should be done as reversible causes may be ruled out. Acute CVA should be a top differential in unexplained encephalopathy. This case brings to light that although it is possible for patients, even the most severe cases who require intubation, to fight this atypical pneumonia, they can rapidly develop extra-pulmonary complications which if goes unrecognized can leave lethal penalties. Reference #1: Avula A, Nalleballe K, Narula N, et al. COVID-19 presenting as stroke [published online ahead of print, 2020 Apr 28]. Brain Behav Immun. 2020;S0889-1591(20)30685-1. doi:10.1016/j.bbi.2020.04.077 Reference #2: Pleasure SJ, Green AJ, Josephson SA. The Spectrum of Neurologic Disease in the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic Infection: Neurologists Move to the Frontlines. JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1065 Reference #3: Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection. New England Journal of Medicine. 2020. doi:10.1056/nejmc2008597. DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Gloria Hong, source=Web Response No relevant relationships by Han Lam, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response

The utility of cerebrospinal fluid white cell count during the prognostic assessment for cryptococcal meningitis patients: a retrospective study

BackgroundThe incidence of cryptococcal meningitis (CM) has gradually increased in recent years. Cerebrospinal fluid (CSF) cytology and cell count are very important for CM on etiology diagnosis and assessment of disease status and therapeutic response. However, the clinical significance of CSF white cell count (WCC) in CM patients is not fully understood. Using longitudinal data of CSF WCC and its relationship with clinical outcomes in CM patients, we aimed to elucidate the clinical significance of this test.MethodsWe retrospectively analyzed the medical records of 150 CM patients admitted to our hospital between January 2008 and December 2018.ResultsCM patients with lower baseline CSF WCC, CSF protein concentration or CD4/CD8 ratio, and those with altered mentation or HIV coinfection were more likely to have poor clinical outcome (P<0.05). CM patients with triple therapy during the induction period presented with a better clinical outcome (P<0.05). Baseline CSF WCC had a moderate positive correlation with peripheral CD4+ T lymphocyte count (r = 0.738, P < 0.001) and CD4+ T lymphocyte percentage (r = 0.616, P < 0.001). The best cut-off value to predict a poor clinical outcome was 40 cells/μL during baseline CSF WCC. The predictive model incorporating longitudinal data of CSF WCC had better sensitivity, specificity, and accuracy than a model incorporating only baseline CSF WCC data.ConclusionsOur results indicated that baseline CSF WCC and changes in CSF WCC over time could be used to assess the prognosis of CM patients.

23. RETROSPECTIVE REVIEW OF ADULT PATIENTS WITH LEPTOMENINGEAL DISEASE SECONDARY TO MELANOMA AT MOFFITT CANCER CENTER: DIAGNOSIS, TREATMENT AND OUTCOMES

BACKGROUNDNearly 5–8% of solid cancers present with leptomeningeal disease (LMD). Patients with LMD have a dismal prognosis with survival measured in weeks-to-months. The pathophysiology of this devastating disease remains unknown.METHODSA retrospective chart review was performed of twenty-five adult patients with LMD due to melanoma who were enrolled in the MCC 50172 clinical trial between 05/26/2015 and 07/17/2018.RESULTSPatients had a median age 63 years (31–80) at diagnosis with LMD. Sixteen had confirmed LMD and five did not meet criteria for LMD, but had positive cerebrospinal fluid (CSF)-circulating tumor cells (CTC’s). Those with LMD had a median KPS of 70 (30–90) at presentation, and symptoms most commonly included altered mentation n=6 (37%), headaches n=4 (25%), focal weakness n=3 (19%), and paresthesia n=2 (12%). Eleven patients were diagnosed by MRI. Ten patients (62%) had positive CSF cytology on first attempt and fourteen (87%) on first-two attempts. Lumbar puncture mean OP was 29.4 cmH2O (18–65), with CSF WBC 21.8/cumm (SD 25.6), RBC 2942.5/cumm (SD 9056.1), and protein 187.6 mg/dL (SD 166.1). CSF-CTC’s CellSearch analysis had a sensitivity of 0.75 (12[12 + 4]) and specificity of 0.44 (4[4 + 5]); PPV 0.71 and NPV 0.50. Twelve patients with LMD had positive CSF-CTC’s. Prior to LMD diagnosis, patients were treated with immune checkpoint inhibitors (ICI’s) n=9 (56%), BRAF+/-MEK inhibitors n=5 (31%), and/or RT n=5 (31%). Patients with LMD were treated with Ommaya n=13 +VPS n=3, WBRT n=7, ICI’s n=5, BRAF+MEK inhibitors n=4, and IT topotecan. LMD patients had a median survival 3.27 months after diagnosis (0.30–39). Two patients outlived their counterparts by 21.1 and 39.0 months. The 2 long-term survivors were treated with WBRT and either ICI, pembrolizumab or ipilimumab+nivolumab.CONCLUSIONClinical studies in LMD can provide critical insights and help to develop improved guidelines and current therapies.

STUDY OF THE CLINICAL PROFILE OF HEPATIC ENCEPHALOPATHY IN TERTIARY CARE HOSPITAL

Introduction Hepatic encephalopathy is the term used to describe the complex and variable changes in neuropsychiatric status that complicates liver disease.Aim- To study the clinical profile of Hepatic Encephalopathy. Objectives -To determine clinical spectrum of Hepatic Encephalopathy and to determine various etiologies precipitating Hepatic Encephalopathy. METHODS- Study area:- Department of medicine at Krishna Institute of Medical Sciences and research institute, Karad. Hospital based prospective, observational and non-interventional study. Patients having altered mental states and neurological impairments along with liver dysfunction present above 18 years. Exclusion Patients below 18 years of age,the patients with other known causes of encephalopathy like uremia, hypertensive encephalopathy, CVA, cerebral malaria, electrolyte disturbances will be excluded from the study. And Patients with underlying active brain diseases. Results 74 patients were enrolled, out of which 66 patients were males and 8 were females. Between the age group of 20 to 88 years with mean age of 50.16 with SD of 14.93.Anorexia (80%), yellowish of eyes (70%), altered sensorium (43.24%) and vomiting were the most widely recognized introducing manifestations in patients with acute hepatic encephalopathy whereas yellow discoloration of eyes (84%) and altered mentation (43.24%) were present with chronic hepatic encephalopathy.On general examination, Icterus, pallor, oedematous feet and ecchymosis were seen in patients with acute hepatic encephalopathy while spider naevi, oedematous feet, palmer erythema, testicular atrophy and Dupuytren’s contractures were seen in patients of chronic encephalopathy.On per abdominal examination, patients with acute hepatic encephalopathy characteristically had hepatomegaly whereas, ascites and dilated veins were seen in those with chronic encephalopathy.History of alcoholism, previous jaundice, Hepatitis B surface antigen,history of previous blood transfusion, Hepatitis C antibody was the most common risk factors for hepatic encephalopathy.Among, clinical features parotid fullness (93.24%) was most common followed by finger clubbing (40.45%), liver palms (40.45%), spider naevi (17.56%), shrunken liver (13.51%) and gynecomastia (9.45%).At the time of admission, most common complications were Ascites (64.86%) followed by altered mentation (43.24%), renal failure (39.18%) and bleeding Diathesis (12.16%).

MON-902 Etomidate - an Under Utilized but Safe and Efficacious Drug to Treat Acute Severe Cushing’s Syndrome- Case Reports of Ectopic ACTH Syndrome from Neuroendocrine Malignancies

Background: Intravenous etomidate infusion, in non-hypnotic doses, rapidly lowers cortisol levels by blocking 11-beta hydroxylation of deoxycortisol to inhibit cortisol production. It is an underutilized drug due to concerns of excess sedation and ICU monitoring. Clinical Case 1: A 44 year-old female with HTN, diabetes, and recently diagnosed pancreatic neuroendocrine tumor with liver metastases presented with altered mentation. Labs showed severe hypokalemia, metabolic alkalosis, serum AM cortisol >60.2 ug/dL (n 6.7-22.6 ug/dL), ACTH of 698.1 pg/mL (n 7.2-63.3 pg/mL), 24-hour urine free cortisol (UFC) of 5791 ug/24hr (n 5-64 ug/24hr), midnight salivary cortisol of 8.04 ug/dL (n <0.01-0.09), and abnormal low dose (LDDST) and high dose (HDDST) dexamethasone suppression tests each with cortisol >60.2 ug/dL. She developed worsening psychosis, likely secondary to hypercortisolism. After ICU transfer, etomidate infusion was initiated at 2.5 mg/hr and titrated upward, leading to rapid drop in cortisol levels and concomitant improvement in mentation. No respiratory or airway difficulties developed. Ketoconazole and metyrapone were started and etomidate was weaned off. Steroids were added once cortisol levels fell below 10 ug/dL as part of “block and replace.” The patient eventually underwent bilateral adrenalectomy with improvement in hemodynamic and blood glucose parameters. She was discharged on physiologic replacement doses of hydrocortisone and fludrocortisone, with no reported issues two months later. Clinical Case 2: A 51 year-old man with one month of hematochezia presented with hypertension, severe hypokalemia, metabolic alkalosis, and QTc prolongation. Colonoscopy was unremarkable; however, labs revealed a cortisol of 43.1 ug/dL, ACTH of 83.6 pg/mL, and 24-hour UFC of 7,494 ug/L, with an abnormally elevated LDDST. Imaging showed a pancreatic mass and multiple hypodense liver lesions. The overall presentation was suggestive of ectopic ACTH syndrome due to metastatic neuroendocrine carcinoma, which was confirmed on biopsy. Chemotherapy, ketoconazole, and metyrapone inadequately lowered cortisol. Etomidate drip was initiated at 3 mg/hr in the ICU, with rapid reduction in cortisol levels to <20 ug/dL without respiratory compromise. Attempts to wean off etomidate were unsuccessful and the patient underwent bilateral adrenalectomy. The surgery was compromised due to extensive liver and pancreatic enlargement, and follow up imaging revealed incomplete resection. 8am cortisol level (off etomidate) was >60.0 ug/dL. Metyrapone and ketoconazole were resumed and hydrocortisone was later initiated for “block and replace”. The patient remains in critical condition. Conclusion: Etomidate-in non- hypnotic doses is useful for the rapid lowering of cortisol levels.

Prediction of Mortality in Sepsis using Rapid Emergency Medicine Score: A Cohort Study

Introduction: Organ dysfunction due to sepsis is manifested as acute rise of 2 points in quick Sequential Organ Failure Assessment (qSOFA) score from baseline, which is assessed by: 1) Systolic Blood Pressure (SBP) ≤100 mmHg; 2) Respiration Rate (RR) ≥22/min; 3) altered mentation, each having one point. For timely and specific management, an early diagnosis and stratification of severity of the sepsis is important. To predict the outcome of sepsis many scoring systems like SOFA, Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Mortality Prediction Model (MPM) have been developed. REMS is simple and feasible scoring system comprising of simple variables like, age in years, Pulse Rate (PR), RR, Mean Arterial Pressure (MAP), Glasgow Coma Scale (GCS) and SpO2 estimation. Aim: The aim of the study was to evaluate the efficacy of REMS score and to validate its utility in patients with sepsis to predict mortality. Materials and Methods: This was an observational, cohort study conducted in the Department of Medicine of SCB Medical College and Hospital, Cuttack. A total of 100 patients of sepsis admitted to medical wards and Intensive Care Unit (ICU) of Medicine department were included in the study. Vital parameters like PR, SBP, RR, GCS, SpO2 were noted. REMS score was calculated for patients with sepsis and septic shock, among survivors and non survivors. Primary outcome was either death or discharged. The observed data was statistically analysed for utility of REMS score in predicting mortality, which is the secondary outcome of the study. Student’s t-test and Mann-Whitney U test were used for comparing normally and non-normally distributed data respectively. Univariate and multivariate logistic regression was done for all parameters in REMS. Results: The average age of the patients was 49 years (SD 14.5) with males and females almost equally distributed. Major source of infection were pneumonia (24%) followed by urinary tract infections (19%). REMS score was calculated on the day of admission of all 100 patients. It clearly distinguished survivors from non survivors (p&lt;0.001). The median value of REMS among non survivors was 9 (7-10), which was highly significant compared to survivors; median value of REMS among survivors was 3.5 (2-5). REMS score was high among patients with septic shock than patients with sepsis {median REMS: 9 (7-10.5) vs. 4 (2-5.75); p&lt;0.001}. All the variables in REMS were significantly associated with mortality, however with multivariate analysis only the RR was independent predictor of mortality. REMS at cut-off score 7 has sensitivity of 87.5%, specificity of 88.2%, Positive Predictive Value (PPV) of 70%, Negative Predictive Value (NPV) of 95.7%, and accuracy of REMS was 88%. Conclusion: REMS score showed a significant difference among survivors and non survivors with higher score predicting higher mortality. Hence, REMS is a valid scoring system that can be used in resource limited emergency departments to predict the mortality in patients with sepsis and septic shock.

Procedural sedation and analgesia in the emergency department

Emergency medicine as a medical specialty has come a long way since its evolution from the now obsolete “Casualty Department.” A prevalent challenge in the emergency department (ED) is safe and effective administration of anesthetic agents to a patient in pain or altered mentation without compromising their airway control and hemodynamics. Fear and unfamiliarity with the use of various anesthetic agents is the major stumbling block in this regard. Procedural sedation and analgesia (PSA) in the ED improve patient satisfaction, reduces physiological stress and allows for rapid return of consciousness after traumatic procedures while providing sedation, analgesia, and amnesia. PSA is a planned service which should be provided under strict monitoring with proper preanesthetic workup and emergency measures easily available. PSA strengthens the armament of the emergency physician, allowing a better understanding of pain control and sedation without resorting to general anesthesia.

Isoniazid Induced Psychosis: A Case Report

Psychosis is a state of altered behaviour and mentation and it is not common in children. Isoniazid is a commonly used drug in the treatment and prophylaxis of tuberculosis. It may cause psychosis if overdosed but rarely with usual recommended doses. We report a case of drug induced psychosis secondary to isoniazid intake in a seven years old boy, who exhibited psychotic features about 10 days after the commencement of anti-TB combination drugs (Directly Observed Treatment Shortcourse) containing Isoniazid. This patient had no past medical or family history of mental illness. Drug induced psychosis was a possibility, and the responsible drug (isoniazid) was stopped. He improved following the withdrawal of isoniazid. Isoniazid psychosis is a major complication as iatrogenic psychiatric complications can greatly impact the patients’ quality of life, which if recognised early can be effectively treated.

Non-convulsive seizures in the encephalopathic critically ill cancer patient does not necessarily portend a poor prognosis

BackgroundNon-convulsive status epilepticus (NCSE) is present in 10–30% of ICU patients with altered mental status (AMS) and is associated to poor outcomes. To our knowledge, there is no data describing the prevalence and outcomes of critically ill cancer patients with AMS associated to non-convulsive seizures (NCS) or NCSE. We aim to describe the outcomes and risk factors of critically ill cancer patients with encephalopathy associated with non-convulsive seizures (NCS).MethodsThis is a 3-year prospective observational study in a mixed oncological ICU at MD Anderson Cancer Center. Data of ICU patients with moderate to severe encephalopathy (Glasgow Coma Score < 13) that underwent EEG monitoring to rule out NCS were collected. Multivariate logistic regression was performed to identify risk factors and outcomes.ResultsOf the 317 patients with encephalopathy who underwent EEG monitoring, 14.5% had NCS. Known risk factors such as sepsis, CNS infection, antibiotics, and cardiac arrest were not associated with increased risk of NCS. Patients with NCS were more likely to have received recent chemotherapy (41.3% vs 21.4%; p = 0.0036), have a CNS disease (39% vs 24.4%; p = 0.035), and abnormal brain imaging (60.9% vs 44.6%; p = 0.041). Patients with lower SOFA scores, normal renal function, and absence of shock were likely to have NCS as the cause of their encephalopathy (p < 0.03). After multivariate analysis, only abnormal brain imaging and absence of renal failure were associated with NCS. Mortality was significantly lower in patients with non-convulsive seizures when compared to those without seizures (45.7% vs 64%; p = 0.022); however, there was no significant association of seizures and mortality on a multivariable logistic regression analysis.ConclusionsNCS in critically ill cancer patients is associated with abnormalities on brain imaging and lower prevalence of organ failure. Diagnosis and treatment of NCS should be a priority in encephalopathic cancer patients, as they can have lower mortality than non-seizing patients. Opposite to other populations, NCS should not be considered a poor prognostic factor in critically ill encephalopathic cancer patients as they reflect a reversible cause for altered mentation.

1416. Nocardia beijingensis: A Rare and Unusual Cause of Intracranial Abscess

BackgroundNocardia species are thin, aerobic, filamentous, gram-positive bacilli that are ubiquitous in soil worldwide. Nocardia infections are divided into three main categories: pulmonary nocardiosis, disseminated nocardiosis, and cutaneous nocardiosis.MethodsWe present a case of cerebral nocardiosis in an immunocompetent patient caused by Nocardia beijingensis (NB).ResultsA 60-year-old Caucasian lady from Florida with type 2 diabetes mellitus, hypertension, hyperlipidemia, presented to the emergency room with complaints of altered mentation. Per husband, she was having episodes of emesis and diarrhea 3 days prior to admission that resolved however, her mentation significantly deteriorated to where she was unable to perform simple chores around the house. Pertinently she had resection of lung mass 2 months prior to admission which found to be benign. Vital sign at admission was stable and on examination, the patient was alert and oriented, however, lethargic appearing. Neurological examination was pertinent for expressive aphasia; however, cranial nerves II-XII were grossly intact. The patient was also found to have a 3 cm by 4 cm, tender, cystic lesion on the left-sided occipital scalp. The remainder of the physical examination was unremarkable. Admission laboratories were remarkable for leukocytosis and hyperglycemia. MRI of the brain was completed that showed multiple areas of vasogenic edema and multiple nodules with the largest being 1.8 cm suggestive of abscesses. She was started empirically on vancomycin, ceftriaxone, metronidazole, and ampicillin. Cerebral spinal fluid showed neutrophilic pleocytosis, low glucose, and high protein. Initial cultures including CSF were negative. Left-sided occipital scalp lesion was excised and sent for pathology and culture. Initial cultures showed gram-positive bacilli, so antibiotics were de-escalated to sulfamethoxazole/trimethoprim and ceftriaxone. Repeat imaging showed improving abscess, and final cultures resulted in NB.ConclusionNB is believed to have originated in Southeast Asia. NB has been associated mainly with infections in immunocompromised. In the United States, the two only other cases of NB described in immunocompetent hosts were interestingly from Florida as well. Disclosures All authors: No reported disclosures.

2704 Urosepsis Is Difficult to Stomach!

INTRODUCTION: Gastric ischemia is a rare condition associated with poor prognosis typically presenting with abdominal pain, GI bleed and altered mentation and may be caused due to states of shock. We present a rare case of gastric ischemia due to urosepsis. CASE DESCRIPTION/METHODS: A 70 year-old male with past medical history of peripheral vascular disease, chronic Foley catheter and dementia presented with altered mentation, hypotension, tachycardia and decreased urine output. The Foley catheter was replaced revealing purulent urine. Initial labs revealed acute kidney injury, lactic acidosis, and leukocytosis. CT abdomen pelvis without contrast revealed gastric pneumatosis with adjacent left upper quadrant portal venous gas and branching portal venous gas throughout the liver. Esophagogastroduodenoscopy was performed which showed proximal gastric ischemia and necrosis from the midbody to the fundus; biopsies revealed acute hemorrhagic gastritis, and gastroenterology recommended resection. General surgery was consulted who recommended conservative management. Patient improved clinically while receiving antibiotic therapy, intermittent nasogastric tube suction, intravenous proton pump inhibitor therapy and parenteral nutrition. Repeat imaging showed resolution of portal gas and gastric pneumatosis and repeat EGD showed resolution of gastric ischemia. DISCUSSION: Gastric ischemia is a serious condition which is under-recognized clinically. Etiologies include systemic hypotension, vasculitis or disseminated thromboembolism. Gastric pneumatosis or portal venous gas on imaging suggest ischemia; EGD with biopsy is the diagnostic gold standard. Gastric ischemia is either managed surgically or medically with fluid resuscitation, nasogastric tube placement to prevent gastric distension and acid reduction along with antibiotics for patients with gastric pneumatosis.

1526 Abdominal Tuberculoma in a Cirrhotic Patient With Disseminated Tuberculosis

INTRODUCTION: Disseminated tuberculosis (TB) is defined as two or more noncontiguous sites due to lymphohematogenous spread by Mycobacterium tuberculosis. Diagnosis is made through isolation of the organism from blood, bone marrow, or from two or more non-contiguous organs. Lymphocytopenia is a risk factor for dissemination. The incidence of disseminated TB is unclear, but of the cases reported in the United States in 2016, both pulmonary and extrapulmonary sites were reported in less than 10% of cases. We present a rare case of an abdominal tuberculoma in cirrhotic patient with disseminated tuberculosis. CASE DESCRIPTION/METHODS: 72 year old Vietnamese female with a history of hepatitis C cirrhosis who presents with altered mentation concerning for stroke. CT head without contrast was negative. She subsequently developed melena with an associated hemoglobin of 6.2 overnight. She underwent upper endoscopy without significant findings. CT chest without contrast showed numerous noncalcified nodules bilaterally as well as the apices concerning for military tuberculosis. BAL positive with AFB stain. Lumbar puncture did not show significant pleocytosis, normal glucose and protein. CSF culture was negative for AFB, cocci, Cryptococcus. Blood cultures, HIV 1/2 Ag/Ab screen 4th generation and serum cocci were negative. CEA was 2.7. MRI head with and without contrast showed multiple enhancing lesions concerning for infection versus malignancy. CT abdomen/pelvis showed a colonic mass in the cecum and ascending colon with thickening in the ileum. Colonoscopy showed a non-obstructing large mas in the cecum. Biopsies of the ileum and cecum were consistent with granuloma formation with necrosis, acid-fast bacilli with confirmation on AFB stain. The patient was started on RIPE therapy. Unfortunately, her encephalopathy did not improve despite 2 weeks of treatment and she was placed on hospice. DISCUSSION: Abdominal tuberculosis (TB) is reported in less than 5% of all cases of TB worldwide. It can present with non-specific symptoms such as fever, weight loss and abdominal pain. Endoscopic findings of intestinal TB vary from ulcers, strictures, nodules to deformed ileocecal valves and fistulas. Patients typically improve within weeks of initiating antituberculous therapy. One case report demonstrated correlation with carcinoembryonic antigen (CEA) pre -and post antituberculous therapy in a patient with multivisceral tuberculosis suggesting it could be a marker to trend response to therapy.