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

Thank You