دانلود کتاب رویکرد مبتنی بر مورد به اختلالات عصبی رایج

A 21-year-old patient presented with complaints of fever for 4 days, limb weakness for 3 days, and altered sensorium for 2 days. According to the patient’s father, he was well 4 days back, then he developed mild fever, which was insidious in onset and not associated with chills and rigor. Same day, patient started having tingling sensa-tion of left lower limb. Next day, patient devel-oped weakness in left upper and lower limbs and had a high fever (104 °F). In local hospital, CT head was done, which showed no significant abnormal findings. Patient also had one episode of jerking of limbs with loss of consciousness lasting for about 1–2 min. After this episode, patient continued to have altered sensorium. Patient was then referred to our center for further management.
The patient presented to emergency depart-ment with low Glasgow Coma Scale (E2M3V2) and was intubated. On examination, his vitals were BP: 140/80 mmHg, pulse: 120/min, tem-perature: 103 °F. Bilateral pupils were equal and reactive to light. There was no disk edema, and movement of extraocular muscles was normal. Corneal and gag reflexes were preserved with no facial deviation. No spontaneous limb move-ments were observed. Muscle tone was reduced, and areflexia was elicited across all limb joints. Plantar extensor was observed in left side, while right side had flexor response. His cerebrospinal fluid was clear with total leukocytes 310/mm3 (polymorphs: 10% and monomorphs: 90%), pro-tein: 38 mg/dL, and sugar: 4.7 mmol/L. A provi-sional diagnosis of acute encephalitis syndrome was made, and the patient was then started on empirical treatment with acyclovir and ceftriax-one. Routine blood investigations with renal and hepatic function tests were normal. The MRI brain T2 fluid-attenuated inversion recovery (FLAIR) sequence showed a bilateral thalamus hyperintense lesion extending to the upper mid-brain region and another hyperintense area in the right medial parietal cortex and subcortex (Fig. 1.1a–c). Herpes simplex I and II and tuber-culosis polymerase chain reactions (PCRs) were negative. Japanese encephalitis serology was found to be positive. The patient’s fever subsided in 3 days after admission. During his stay in the intensive care unit, the patient developed ventilation- associated pneumonia, and a trache-ostomy was done on the 15th day of admission. In about 1 month of admission, mild improve-ment in sensorium was noted, and he was able to follow simple commands. During discharge, he was still bed bound and able to move bilateral distal fingers with no further improvement in cognitive function.