55/F altered sensorium since 10 days

55 year old female ,farmer by occupation 
Was brought to casualty in altered sensorium since 10 days



Patient was apparently asymptomatic 15 days ago 
Then developed fever - for 2 days ,high  grade , with chills        
Then on day 3,4 - patient developed involuntary movements (tremors ) of both upper limbs 
With weakness of both upper limbs from day 4 
And slurring of speech 
Taken to outside hospital in day 5 
Found to have hypoglycemia (grbs -27 mg/dl )

Since admission in outside hospital 
Patient developed altered sensorium 
Fluctuating sensorium+nt ( unable to recognise people sometimes ) 
Self talking +nt 
Hallucinations+nt
Involuntary micturition+nt 
Irrelevant talking +nt 
No involuntary defecation , involuntary mivuemk

Diagnoses as - 
acute gastroenteritis with dehydration
Acute kidney injury 
? Metabolic encephalopathy 
Recurrent hypoglycemia 
Type 2 dm
Hypertension 

Treated and discharged with antibiotics,antiepileptics ( topiramte)
Anti psychotics ( olanzepine) anti htn ,ohas and other supportive treatment .


Then patient was brought to our hospital 1 day ago 
At presentation 
Patient unable to walk without support since 15days (bed ridden since onset of fever ) 


Past history - 
Known case of diabetes since 10 years 
H/o burning sensation in soles a/w pain since 5 years 
So stopped going to fields since 3 years 
K/c/o  hypertension since 3 years
H/o recurrent hospital visits for diabetes and fever ,was prescribed antibiotics frequently since 2023 

Vitals 
Patient conscious, incoherent,non cooperative 
Pr - 96 bpm
Bp - 130/80 mmhg
Grbs - 108 mg/dl

CNS examination 
Tone - normal in all limbs 
Power - 5/5 in upper limbs 
              4/5 in lower limbs 
Reflexs. 
     B.   T.    S.   K.   A.   P
R. +2   +1 +1   +2   -    F 
L                    +1      -    F

Sensory and cerebellar examination - couldn't be done 

Hyperalgisia - present 

Kernig sign - absent 
Brudzinski - absent 
Neck stiffness - absent 

PROVISIONAL DIAGNOSIS ON DAY OF ADMISSION 

ALTERED SENSORIUM SECONDARY TO 
ENCEPHALITIS ?VIRAL ? AUTOIMMUNE 
? ELECTROLYTE DISTURBANCES
? NEUROGLYCOPENIA 


MRI BRAIN 









HIV - NON REACTIVE 
HBSAG - - NEGATIVE 
HCV ANTIBODIES - NON REACTIVE 
Ophthalmology opinion was taken i/v/o raised ict features 

No signs of raised ict 
No signs of diabetic retinopathy noted 

LUMBAR PUNCTURE WAS DONE ON DAY OF ADMISSION 

CSF CYTOLOGY - FEW SCATTERED LYMPHOCYTES PRESENT 

COURSE SINCE DAY 1 
no fever spikes 
Grbs was maintained by Ivf 5% dextrose for 1 day 
Vitals - stable 

Treatment given 

Ivf ns @75ml/hr
Inj dexamethasone 8mg iv tid 
Inj hai s/c tid acc to grbs 
Inj optineuron 1 amp in 100ml ns iv od
Tab telma 40mg once daily 

Diagnosis 

ALTERED SENSORIUM SECONDARY TO ENCEPHALITIS 
?AUTOIMMUNE ?PARANEOPLASTIC ?VIRAL 
? AKI ON CKD 
K/C/O TYPE II DM SINCE 14 YEARS WITH SENSORY PERIPHERAL NEUROPATHY
K/C/O HYPERTENSION SINCE 3 YEARS 
MILD ANEMIA SECONDARY TO IDA (?ANEMIA OF CHRONIC DISEASE) 





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