scholarly journals Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis presenting to the emergency department with status epilepticus

CJEM ◽  
2014 ◽  
Vol 16 (05) ◽  
pp. 425-428 ◽  
Author(s):  
Brodie Nolan ◽  
Katharina Plenk ◽  
David Carr
Keyword(s):  
Emergency Department ◽  
Status Epilepticus ◽  
Mental Status ◽  
Young Patients ◽  
Complete Recovery ◽  
Altered Mental Status ◽  
Emergency Physicians ◽  
Varicella Zoster ◽  
Aspartate Receptor ◽  
Nmdar Encephalitis

ABSTRACT Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a recently described and underdiagnosed entity that typically affects young, previously healthy individuals. Patients usually present in phases, which may include refractory seizures, psychosis, unresponsiveness, and autonomic instability. The diagnosis of anti-NMDAR encephalitis is challenging; however, prompt diagnosis and early treatment can lead to complete recovery. The incidence of anti-NMDAR encephalitis may be as high as four times that of encephalitis from herpes simplex, varicella-zoster, and West Nile viruses; however, it remains an underrecognized disorder. Early initiation of immunotherapy in anti-NMDAR encephalitis has been found to improve patient outcomes. Because of this, emergency physicians must be vigilant and consider this diagnosis in patients with altered mental status in whom a toxicologic or other etiology is not suspected. Early consideration of this diagnosis can facilitate urgent neurology consultation and prevent diagnostic delays arising from psychiatric referrals. It is essential to consider this diagnosis in suspicious emergency department presentations, particularly young patients who present with altered mental status, psychosis, or new-onset seizure activity when other obvious causes are ruled out. Emergency physicians should discuss the possibility of empirical intravenous immunoglobulin administration with neurology consultants if anti-NMDAR encephalitis is suspected. We describe the case of a 20-year-old man with anti-NMDAR encephalitis who presented to the emergency department with status epilepticus.

scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

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.

scholarly journals Fat Embolism and Nonconvulsive Status Epilepticus

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Yanetsy Olivera Arencibia ◽  
Mai Vo ◽  
Jennifer Kinaga ◽  
Jorge Uribe ◽  
Gloria Velasquez ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Mental Status ◽  
Supportive Therapy ◽  
Altered Mental Status ◽  
Fat Embolism ◽  
Nonconvulsive Status Epilepticus ◽  
Altered Level ◽  
Fat Embolism Syndrome ◽  
Embolism Syndrome ◽  
Wide Range

Fat embolism syndrome (FES) typically occurs following orthopedic trauma and may present with altered mental status and even coma. Nonconvulsive status epilepticus is an electroclinical state associated with an altered level of consciousness but lacking convulsive motor activity and has been reported in fat embolism. The diagnosis is clinical and is treated with supportive care, antiepileptic therapy, and sedation. A 56-year-old male presented with altered mental status following internal fixation for an acute right femur fracture due to a motor vehicle accident 24 hours earlier. Continued neuromonitoring revealed nonconvulsive status epilepticus. Magnetic resonance imaging of the brain showed multiple bilateral acute cerebral infarcts with a specific pattern favoring the diagnosis of fat embolism syndrome. He was found to have a significant right to left intracardiac shunt on a transesophageal echocardiogram. He improved substantially over time with supportive therapy, was successfully extubated on day 6, and discharged to inpatient rehabilitation on postoperative day 15. Fat embolisms can result in a wide range of neurologic manifestations. Nonrefractory nonconvulsive status epilepticus that responds to antiepileptic drugs, sedation, and supportive therapy can have a favorable outcome. A high index of suspicion and early recognition reduces the chances of unnecessary interventions and may improve survival.

scholarly journals Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane

2012 ◽  
Vol 3 (4) ◽  
pp. 270 ◽  
Author(s):  
Hai-yu Xiao ◽  
Yu-xuan Wang ◽  
Teng-da Xu ◽  
Hua-dong Zhu ◽  
Shu-bin Guo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Fast Lane

Emergency Management of Epilepsy and Seizures

2019 ◽  
Vol 39 (01) ◽  
pp. 073-081 ◽  
Author(s):  
Carl Bazil ◽  
Anna Bank
Keyword(s):  
Emergency Department ◽  
Status Epilepticus ◽  
Emergency Management ◽  
Emergency Department Visits ◽  
Emergency Physicians ◽  
Common Cause ◽  
Medical Evaluation ◽  
Symptomatic Seizures ◽  
Acute Symptomatic Seizures ◽  
New Onset

AbstractSeizure- and epilepsy-related complications are a common cause of emergency medical evaluation, accounting for 5% of 911 calls and 1% of emergency department visits. Emergency physicians and neurologists must be able to recognize and treat seizure- and epilepsy-related emergencies. This review describes the emergency evaluation and management of new onset seizures, breakthrough seizures in patients with known epilepsy, status epilepticus, acute symptomatic seizures, and acute adverse effects of antiepileptic drugs.

Altered Mental Status in the Emergency Department

2019 ◽  
Vol 39 (01) ◽  
pp. 005-019 ◽  
Author(s):  
Austin Smith ◽  
Jin Han
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Detailed History ◽  
Radiographic Testing ◽  
Life Threatening ◽  
Secondary Survey ◽  
Acute Changes ◽  
Department Evaluation ◽  
The Brain

AbstractAltered mental status is an umbrella term that covers a broad spectrum of disease processes that vary greatly in chronicity and severity. Causes can be a primary neurologic insult or a result of a systemic illness resulting in end-organ dysfunction of the brain. Acute changes in mental status are more likely than chronic changes to be immediately life-threatening and are therefore the focus of this review. Given the potential time-sensitive nature, acute changes in mental status must be addressed immediately and with urgency. We recommend a primary survey followed by a secondary survey with special attention to immediate life-threatening reversible causes. We then recommend a systems-based approach searching for any other life-threatening or reversible causes. Because the differential for altered mental status is broad, a comprehensive emergency department evaluation including a detailed history and physical exam as well as laboratory and radiographic testing is needed.

scholarly journals 1111. Characterization of Antibiotic Ordering in Patients with Mental Status Changes and Presumed Urinary Tract Infection in Patients 65 and Older

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S395-S396
Author(s):  
Nicole Harrington ◽  
Jessica Leri ◽  
Scott Shoop
Keyword(s):  
Internal Medicine ◽  
Emergency Department ◽  
Urinary Tract ◽  
Mental Status ◽  
Asymptomatic Bacteriuria ◽  
Altered Mental Status ◽  
Practice Change ◽  
Antibiotic Selection ◽  
Common Diagnosis ◽  
Tract Infections

Abstract Background Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures. Methods A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge. Results A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility. Conclusion These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change. Disclosures All authors: No reported disclosures.

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