Development of a Prediction Model for Diagnosis of Acute Poisoning in Patients with Altered Mental Status and Absent History of Alcohol/Drug Ingestion

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

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Altered Mental Status and a Retro-auricular Mass

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100005205 ◽

2006 ◽

Vol 33 (3) ◽

pp. 317-319

Author(s):

Lauren M. Segal ◽

Angela Walker ◽

Eric Marmor ◽

Errol Stern ◽

Mark Levental ◽

...

Keyword(s):

Eye Movements ◽

Glasgow Coma Scale ◽

Emergency Room ◽

Mental Status ◽

External Auditory Canal ◽

Posterior Wall ◽

Altered Mental Status ◽

Facial Paresis ◽

Coma Scale ◽

History Of

A 29-year-old woman was found lying unconscious in the shower. There was a two-day history of headache and dizziness. In the emergency room, she was initially stuporous (Glasgow Coma Scale 10/15), afebrile, bradycardic and hypertensive. She exhibited roving, conjugate eye movements, left facial paresis (including frontalis), left ptosis, diffuse hypotonia, extensor plantar responses bilaterally and a 1.5 cm warm, fluctuant mass with surrounding erythema behind the left ear (Figure 1). Otoscopy revealed a bulge in the posterior wall of the left external auditory canal.

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LO57: Validation of the Ottawa 3DY in community seniors in the ED

CJEM ◽

10.1017/cem.2017.119 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S47 ◽

Cited By ~ 3

Author(s):

C. Bédard ◽

P. Voyer ◽

D. Eagles ◽

V. Boucher ◽

M. Pelletier ◽

...

Keyword(s):

Cognitive Impairment ◽

Cognitive Dysfunction ◽

Mental Status ◽

Medical Condition ◽

Previous History ◽

Altered Mental Status ◽

Initial Interview ◽

Nursing Facility ◽

Trained Research Assistant ◽

History Of

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.

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714. Invasive Fungal Infection Caused by Curvularia Species in a Patient with Intranasal Drug Use: A Case Report

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.911 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S456-S457

Author(s):

Bakri Kulla ◽

Jason Pham ◽

McKenna Johnson

Keyword(s):

Case Report ◽

Head And Neck ◽

Mental Status ◽

Sphenoid Sinus ◽

Altered Mental Status ◽

The United States ◽

Fungal Sinusitis ◽

Invasive Fungal Sinusitis ◽

History Of ◽

Curvularia Species

Abstract Background Invasive fungal infections (IFIs) are uncommon infections that account for approximately 27.2/100,000 cases per year in the United States. One form of IFI is chronic invasive fungal sinusitis (CIFS). If untreated, invasion into neighboring structures may cause altered mental status, seizures, strokes, proptosis, and intracranial complications. Case Report An afebrile 43-year-old female with a history of polysubstance abuse presented to the ED due to altered mental status, left sided facial droop, right sided hemiparesis, and slurred speech. The patient was somnolent but arousable to stimuli and appeared acutely ill. The patient’s mother reported a history of cocaine abuse, which was confirmed on urine toxicology. A CT head and neck with contrast revealed subacute basal ganglia lacunar infarcts and a left sphenoid opacity with scattered hyperintensities and erosive changes [Figure 2]. One month prior, she had been diagnosed with a left superior pole kidney mass and a left-sided enlarged periaortic lymph node containing multiple noncaseating granulomas and GMS stains positive for fungal hyphae [Figure 1]. The patient underwent nasal endoscopy with tissue biopsy. Tissue showed necrotizing invasive fungal sinusitis with granuloma formation and foreign-body giant cell reaction. Fungal speciation of the tissue culture showed Curvularia species was placed on IV voriconazole. While the infection stabilized, her neurologic deficits did not significantly improve. She was discharged to inpatient rehabilitation. Figure 1. Coronal and axial view of left upper pole kidney mass with perinephric fat stranding. Figure 2. MRI brain CTA Head and Neck with contrast in axial plane showing multifocal infarcts likely represent complications of fungal basilar meningitis secondary to the left sphenoid sinus disease. Imaging also shows irregular erosive change at the anterior aspect of the sella turcica, through the planum sphenoidale, and bony defect of the sphenoid sinus. Methods Results Conclusion Intranasal use of cocaine causes vasoconstriction to elicit sinonasal tissue ischemia. With extended use, chronic mucosal inflammation can occur that can result in sinonasal osteocartilaginous necrosis and potential for infection. CIFS is infrequently diagnosed and its indolent nature with progression over weeks or months can make diagnosis and treatment difficult. The most frequent fungal species identified are the Aspergillus species, but Curvularia species have been found as well. CT and MRI scanning can be suggestive, but are not sufficiently specific or sensitive. The main forms of interventional modalities include surgical debridement and antifungal therapy to maximize survival Disclosures All Authors: No reported disclosures

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A Case Report of Steroid Responsive Nivolumab-Induced Encephalitis

Cancer Control ◽

10.1177/1073274817729069 ◽

2017 ◽

Vol 24 (5) ◽

pp. 107327481772906 ◽

Cited By ~ 9

Author(s):

Kaja Richard ◽

Jacqueline Weslow ◽

Stephanie L. Porcella ◽

Sowmya Nanjappa

Keyword(s):

Mental Status ◽

Checkpoint Inhibitors ◽

Early Recognition ◽

Signs And Symptoms ◽

Altered Mental Status ◽

Oral Steroid ◽

Gradual Improvement ◽

Stage 4 ◽

History Of ◽

Intravenous Steroids

Nivolumab (Opdivo) approval for the treatment of non-small cell lung cancer (NSCLC) prompts recognition of its future use in various cancers. Although rare, occurring in 1% to 3% of treated cases, nivolumab along with other immune checkpoint inhibitors are associated with immune-related encephalitis. With its prospective use, nivolumab-induced encephalitis illustrates the necessity of early recognition and successful management to decrease morbidity and mortality. We describe a treated case of nivolumab-induced encephalitis. A 74-year-old male with a history of stage 4 squamous NSCLC presenting with insidious altered mental status following his first dose of nivolumab. After an extensive workup that proved negative, the patient received intravenous steroids with gradual improvement of mental status. Patient subsequently returned to baseline and was discharged with oral steroid taper. Nivolumab-induced encephalitis is a diagnosis of exclusion with nonspecific signs and symptoms. Immediate recognition of patients prescribed nivolumab chemotherapy could potentially prevent fatal complications of neurotoxicity.

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Is Spontaneous Hypoglycemia a Feature of XLID Type Nascimento?

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.793 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A389-A390

Author(s):

Amin A L Mardini ◽

Ishita Singh

Keyword(s):

Intellectual Disability ◽

Amino Acid ◽

Mental Status ◽

Genetic Disorder ◽

Altered Mental Status ◽

Acth Stimulation ◽

Normal Limits ◽

First Case ◽

Additional Imaging ◽

History Of

Abstract Introduction: X-linked intellectual disability (XLID) type Nascimento is a rare, under-diagnosed genetic disorder caused by intragenic mutations in the UBE2A gene. The syndrome was first described in 2006 by Nascimento et el. It is characterized by intellectual disability, dysmorphic facial features, skin anomalies, hypotonia, impaired speech, and seizures. To date, there is no literature to suggest that it affects glucose homeostasis. Case: A 63-year-old male with a history of XLID (mutation in UBE2A pL112P variant), seizures, dementia, stage II CKD, polycystic kidneys, and hyperkalemia presented to the emergency department with altered mental status and blood glucose (BG) of 22 mg/dL. Mental status improved after correction of hypoglycemia. He had multiple admissions for hypoglycemia, however, no history of diabetes mellitus, or use of hypoglycemia inducing medications. Home medications included Patiromer for hyperkalemia. Family history was remarkable for XLID type Nascimento in his brother and sister’s son. Imaging and laboratory studies conducted on prior admissions were inconclusive. Abdominal CT scan showed a 6mm cyst in the head of the pancreas, but no mass. A 72-hour fast after holding dextrose infusion did not yield a clear biochemical differential. BG 51 mg/dL, Insulin <0.5 (3.0–25 mU/L), C-peptide 0.6 (1.1–4.4 ng/mL), pro-insulin 3.2 (0.0–10.0 pmol/L), β-hydroxybutyrate 0.2 (<0.6 mmol/L). BG increased to greater than 25 mg/dL with 1 mg IV glucagon. Insulin antibody was negative (<5 uU/ml). IGF-1, IGF-2 were low at 17 (49–188 ng/mL) and 142 (333-967ng/mL) respectively. Thyroid function and ACTH stimulation test were within normal limits. Aldosterone <0.1(0.0–30 ng/dL), renin 0.195 (0.167–5.38 ng/mL/hr). Urine metabolic screen, urine amino acid screen, plasma amino acid screen and white cell lysosomal enzymes were normal for the nephew and not performed in our patient. The patient’s family requested not pursuing a repeat 72-hour fast, additional imaging or invasive procedures. Dexamethasone 0.5mg orally at bedtime was started which improved blood sugars and patient was discharged. He presented 2 weeks later with recurrent hypoglycemia. Dexamethasone was titrated to 1.5 mg with no improvement. Diazoxide 3mg/kg/day was subsequently started while dexamethasone was tapered and discontinued. Hypoglycemia did not recur. Conclusion: This is the first case report describing spontaneous hypoglycemia in an individual with XLID type Nascimento. Our patient also had hyporeninemic hypoaldosteronism which raises the question of endocrine abnormalities as a manifestation of XLID type Nascimento and if hypoglycemia is an inborn error of metabolism in this patient.

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Is this Withdrawal or Intoxication? Case Report Regarding Complications of Unregulated Use of Tianeptine, Etizolam, and Phenibut in the USA

CNS Spectrums ◽

10.1017/s1092852920002734 ◽

2021 ◽

Vol 26 (2) ◽

pp. 169-169

Author(s):

Sadia B. Ghani ◽

Eric Taylor ◽

Siddesh Gopalakrishnan

Keyword(s):

Substance Use ◽

Mental Status ◽

Altered Mental Status ◽

Easy Access ◽

The Internet ◽

Normal Limits ◽

Concurrent Use ◽

The Usa ◽

History Of ◽

Benzodiazepine Withdrawal

AbstractBackgroundThe internet allows easy access for the sales of psychoactive agents that are not regulated by the FDA. Some of those agents are used to help manage anxiety, depression and sleep, such as tianeptine, etizolam, and phenibut. These medications have the potential for abuse and potentially leading to altered mental status when intoxicated or withdrawing. This presents a challenge to clinicians who may not be aware of availability of such substances. Available literature has discussed the use of above substances individually, but how do you treat if there is use of more than one substance with different mechanisms of actions? Here we present a case of an adult male who has used all three agents simultaneously, leading to a hospital admission.Case HistoryA 32-year-old male presented to the emergency department (ED) for altered mental status (AMS). He has a documented history of anxiety but was never treated with prescription medications. No history of substance use was documented. He was self-medicating with concurrent use of tianeptine (atypical antidepressant with mu agonist properties,) phenibut (GABA mimetic) and etizolam (a benzodiazepine-like agent). During his stay, he was agitated and delirious with reports of visual hallucinations. Neuroimaging and lab studies were within normal limits, EEG showed no seizure activity. Over the course of his hospital stay, he was started on Depakote for agitation, a Valium taper for suspected benzodiazepine withdrawal and prevention of seizures, Seroquel for delirium, and baclofen for suspected GABAergic withdrawal symptoms. The patient’s AMS improved and he was discharged on hospital day 10.ConclusionsThis case illustrates the difficulty managing poly-substance use/abuse and stresses the importance for physicians to screen for psychoactive agents purchased over the internet or over the counter to improve treatment outcomes. Continued discussions with patients regarding risks/benefits of use of such substances would be beneficial and help increase awareness.

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Altered Mental Status

Acute Care Casebook ◽

10.1093/med/9780190865412.003.0034 ◽

2018 ◽

pp. 172-175

Author(s):

Cynthia Oliva

Keyword(s):

Airway Management ◽

Mental Status ◽

Elderly Person ◽

Noninvasive Positive Pressure Ventilation ◽

Altered Mental Status ◽

Positive Pressure ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Increased Risk ◽

History Of

This case illustrates the diagnostic approach to evaluating an elderly person with altered mental status. It is important to maintain a broad differential of possible etiologies contributing to a decreased level of alertness. In this case, the patient suffers from hypercarbia due to hypoventilation. This patient is at increased risk of hypoventilation due to his history of chronic obstructive pulmonary disease and the administration of narcotic pain medication. Airway management is a top priority during the resuscitation of a patient suffering from hypercarbia. Methods of airway management include ensuring a patent airway, the administration of oxygen, initiating noninvasive positive pressure ventilation, and, if these measures fail, endotracheal intubation.

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An Imperfect Marker: SLE and TTP-Like MAHA Without Low ADAMTS13

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/23247096211029746 ◽

2021 ◽

Vol 9 ◽

pp. 232470962110297

Author(s):

Neha V. Chiruvolu ◽

Jonathan Scott ◽

Sam S. Yeh

Keyword(s):

Mental Status ◽

Lupus Erythematosus ◽

Clinical Signs ◽

Altered Mental Status ◽

Microangiopathic Hemolytic Anemia ◽

Systemic Lupus ◽

Thrombocytopenic Purpura ◽

Chronic Anemia ◽

Prompt Treatment ◽

History Of

Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal condition that can be challenging for clinicians to identify in the setting of autoimmune diseases such as systemic lupus erythematosus (SLE). This difficulty is compounded when a patient presents with all of the clinical signs of a TTP-like microangiopathy, however, with near normal ADAMTS13. This case report describes a 44-year-old female with a history of SLE who was hospitalized with acute on chronic anemia, thrombocytopenia, and altered mental status. The patient’s ADAMTS13 was mildly low; hence, she was initially treated for SLE-associated immune thrombocytopenic purpura without any clinical response. The patient then underwent plasmapheresis (plasma exchange [PLEX]) for treatment of a suspected TTP-like microangiopathy. She responded to PLEX with improvement in her platelet count and mental status. This case illustrates the importance of considering TTP-like microangiopathic hemolytic anemia in the differential for patients with a history of SLE presenting with clinical signs of TTP even in the setting of near-normal ADAMTS13, thus warranting prompt treatment with PLEX.

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Hypoxic-ischemic encephalopathy in a young man due to tramadol overdose

Journal of Emergency Practice and Trauma ◽

10.34172/jept.2019.21 ◽

2019 ◽

Vol 6 (2) ◽

pp. 112-114

Author(s):

Zahra Ataee ◽

Bita Dadpour

Keyword(s):

Side Effects ◽

Mental Status ◽

Altered Mental Status ◽

Hypoxic Ischemic Encephalopathy ◽

Adequate Treatment ◽

Opioid Mechanisms ◽

History Of ◽

Anaphylactoid Reactions ◽

Therapeutic Doses ◽

Ischemic Encephalopathy

Objective: Tramadol is a synthetic analgesic with two mechanisms. The opioid and non-opioid mechanisms are responsible for tramadol side effects. Non-opioid side effects of tramadol are due to the reuptake inhibitions of serotonin and norepinephrine. Some of the side effects include anaphylactoid reactions, CNS depression, hypoglycemia, hypotension, respiratory depression, seizures, and serotonin syndrome. Seizure may happen in therapeutic doses. If the frequency of tramadol seizures increases, ischemic brain injury and hypoxic-ischemic encephalopathy can be induced. Case Report: We report a young man with a history of tramadol abuse that was admitted with status epilepticus in Imam Reza hospital in Mashhad, Iran. Due to his altered mental status, he was intubated and antiepileptic agents were prescribed. He was transferred to ICU. After regaining consciousness, he was extubated and with the prescription of rehabilitation support he was discharged. Conclusion: Tramadol is a synthetic analgesic agent with less potential for dependence. It is important to mention that the overdose of this drug is common. This drug has two mechanisms. This paper reports a case that developed generalized tonic clonic seizures due to tramadol and hypoxic ischemic encephalopathy. With adequate treatment and supportive care, patient’s mental status improves and he/she can be discharged.

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