Delirium in a 74-year-old man : correct imaging revealed the truth
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Transcript of Delirium in a 74-year-old man : correct imaging revealed the truth
Delirium in a 74-year-old man: correct imaging revealed the truth
Dr- Wani delirium in 74 yr old
OVERVIEW What is delirium?
acute onset and fluctuating symptoms disturbance of consciousness (including inattention) at least one of the following:
Disorganised thinking, Disorientation, Memory impairment or perceptual disturbance Evidence of a putative causal medical condition
DSM-IV criteria
FIGURE 156-3 Diagnosis of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). CDNOS, cognitive disorder not otherwise specified.
Walsh: Palliative Medicine 1st ed
OVERVIEW
“The Scream” by Edvard Munch (1893).
OVERVIEW
CASE PRESENTATIONHistory: A 74-year-old man with known hypertension and benign prostatic hyperplasia presented with a 1-week history of fever. The patient received amoxicillin and paracetamol Four days later the patient became confused and refused to take the treatment orally.
Physical examination: confused, disoriented and hypoactive. Pulse rate was 102 bpm, temperature 37.9°C and blood pressure was 150/70 mmHg. The rest of the examination was unremarkable
there was no focal neurological deficit
Investigations:
WBC 4.1/mm3 urine analysis : 6–12 pus cells per HPFESR : 45 mm in the first hour. Serum electrolytes , renal and liver functions : normal CT scan brain : normal.
CASE PRESENTATION
Hospital Course:
Serology for HIV, brucella and salmonella were negative. However, serology for dengue fever was
positive .
The patient’s consciousness level deteriorated and fever continued
WBC decreased to 2.45/mm3 streptococcus group D from urine sensitive to cefipime
The patient was started on cefipime 2 g every 12 hours. Ultrasonography confirmed prostatic enlargement
As treatment of UTI
?CASE PRESENTATION
CSF Finding
Protein = 0.9 g/l total cell count = 45 (90% lymphocytes). Cultures, latex and acid-fast bacillus staining were negative in the CSF.
Polymerase chain reaction for dengue was negative and the patient’s condition deteriorated . Work-up for underlying malignancy was inconclusive.
CASE PRESENTATION
Imaging :
Repeat CT was reported normal except for mild
dilatation of ventricle
MRI without contrast was
normal
However, contrast-enhanced
MRI revealed peculiar ring
enhancing lesions
CASE PRESENTATION
OVERVIEW More imaging:
OVERVIEW Differential Diagnosis
Sepsis-induced delirium, dengue meningo-encephalitis, toxoplasmosis and neurocysticercosis.
Out come
Treatment Antibiotics, anti-tubercular medication and dexamethasone.
Improved and is on regular follow-up.
DISCUSSIONpredisposing factors for delirium in elderly
dementia hypertension medications male gender
alcoholism
benzodiazepines
Hypernatraemia malnutrition
smoking vision impairment severe illness
DISCUSSION
precipitating factors for delirium in elderly physical restraint
anticholinergics
severe illness
infections
cerebrovascular attacks
polypharmacy
bladder catheterisation
major stress
DISCUSSION Some studies show:
associations between
delirium and cortical atrophy
• but they did not control for potential confounders
reduced regional
cerebral blood flow
• but the data were limited and somewhat inconsistent
DISCUSSION Imaging of the brain in acute confusion :
evealed variable results Only 14% of the cases had pathological lesions
DISCUSSION CNS Tuberculosis:
difficult to diagnose, despite revolution in neuroimagin
altered sensorium is reported in more than 40% of the cases in some studies.
Tuberculomas of brain and spinal cord have been reported in cases of associated military tuberculosis, but our case had no evidence of tuberculosis at any other site.
ConclusionConclusion:
• ELDERLY PATIENTS WITH DELIRIUM AND SEPSIS NEED OPEN-MINDED APPROACH .
•BRAIN IMAGING, ESPECIALLY MRI, MAY REVEAL UNUSUAL AND POTENTIALLY REVERSIBLE LESIONS AND MUST BE CONSIDERED.
Learning points
underlying serious illness
can present with delirium
Imaging for the brain must be
selected on case by case basis.
Tuberculomas may involve any part of the brain tissue without focal neurological deficits.
Done by :Dr. Abdulmajed Wani
Dr- Wani delirium in 74 yr old
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