SESSION TITLE: Critical Care Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: Meningoencephalitis, inflammation of brain parenchyma and meninges, often requires critical care management due to potential for rapid neurological decline and severe disturbances in consciousness, even coma or death. Distinguishing between microbial, autoimmune, vasculitic, or drug-induced etiology is critical in providing timely treatment and minimizing disease sequela. We present a case of young healthy woman admitted to the ICU for meningoencephalitis, who was found to have a rare cause for her symptoms.
CASE PRESENTATION: A 30 year old Caucasian woman was placed on Trimethoprim-Sulfamethoxazole (TMP-SMX) for chin impetigo three days prior to elective augmentation mammaplasty and abdominoplasty. She presented to her general physician two days after the procedure, five days into her antibiotic course, with fever and morbilliform truncal rash. Laboratory data showed leucopenia and thrombocytopenia (WBC 0.5 x 103µL 41% neutrophils, 0% eosinophils, platelets 126 K/CU MM) at which time TMP-SMX was stopped and patient was admitted for neutropenic fever. Four hours after admission she required ICU care for altered mental status with impaired comprehension and repetition but intact motor speech. Exam was significant for right leg weakness, right arm rigidity, absence of fever, and well healing abdominal and breast surgical incisions. Lumbar puncture showed elevated opening pressure (36 mmHg), elevated protein (263mg/dL) and WBC 6 x 103µL (80% lymphocyte). MRI brain showed cerebral sulcal and cerebellar signal changes with white matter signal abnormalities suspicious for meningoencephalitis (Image 1). Infectious work-up was negative, including negative CSF culture, PCR for HSV, EBV, VZV, enterovirus. Empiric dexamethasone was begun for possible drug induced inflammation. Patient’s neurological exam improved shortly after receiving IV dexamethasone and she returned to neurological baseline within three days.
DISCUSSION: The patient’s negative infectious, vasculitis, and rheumatologic workup and temporal association with drug exposure supported diagnosis of TMP-SMX induced meningoencephalitis. Her pancytopenia was also attributed to drug effect. TMP-SMX CNS disease may range from psychosis to aseptic meningitis, however brain parenchymal involvement is scarcely seen. In Bruner et al.’s review of 41 cases of TMP-SMX induced aseptic meningitis, only one case showed encephalitic changes on brain imaging, making this case an unusual but important example of drug-related toxicity requiring critical care.
CONCLUSIONS: TMP-SMX-induced CNS disease varies in presentation and may be rare however should be considered in altered patients with history of drug exposure.
Reference #1: Bruner K, Coop C, White K. Trimethoprim-sulfamethaxazole-induced aseptic meningitis-not just another sulfa allergy. Annals of Allergy Asthma and Immunology. 2014; 113.
Reference #2: Moris G, Garcia-Monco JC. The challenge of drug-induced aseptic meningitis revisited. JAMA Internal Medicine. 2014; 174(9):1511-2.
DISCLOSURE: The following authors have nothing to disclose: Naseem Alavian, Ritwick Agrawal, Simon Yau
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