TO WHOM SO EVER IT MAY CONCERN
THIS MESSAGE IS AN SOS FROM INDIA.WE REQUIRE IMMEDIATE GUIDANCE AND ADVICE
FROM DOCTORS ALL OVER THE WORLD TO SAVE THE LIFE OF A YOUNG LADY WHOSE
CASE SHEET IS PRESENTED BELOW.
IF YOU COME ACROSS THIS MESSAGE PLEASE PASS ON THE SAME TO DOCTORS KNOWN
TO YOU.
ADVICE AND SUGGESTIONS MAY BE SENT TO THE E-MAIL ADDRESS GIVEN BELOW.
rajaram at giasmd01.vsnl.net.in
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VOLUNTARY HEALTH SERVICES
Dr. ACHANTA LAKSHMIPATHI NEUROSURGICAL CENTRE
ADYAR, MADRAS - 600 013.
Head of the Department
Brigader (Hony.) B.RAMAMURTHI
Neurosurgeons
Dr. R.RAVI, M.S. (Neuro) F.R.C.S. Ed. (S.N)
Dr. M.C.VASUDEVAN, M.D
Dr. K.SRIDHAR, Dip., N.B.E. (NEURO SURG.,)
Name : SUJATHA
Age : 28 years
Sex : Female
Date of Admission : 16.9.96
Date of Discharge : 16.10.96
Diagnosis : POST ENCEPHALITIC SEQUELAR
--------------------------
COMPLAINTS : Admitted with h/o sudden LOC on 27.8.96.
No h/o seizures, preceeding headache,
vomiting, visual disturbances, fever
trauma or ear discharge. H/o multiple
migratory joints swellings. No h/s/o
vasculitis. Was remaining the same since
then. Was treated at Appollo Neuro Hospital
where she was put on a ventilator,
tracheostomy was done and gradually weaned
off the ventilator.
EXAMINATION : Unconscious, no eye opening or verbal
response, decerebrating to pain, left pupil
8 mms no reaction with ptosis and adducted
position of the left eye, right eye
normal. Other cranial nreves normal. DTR
all exagerated, plantar bilaterally
extensor, absent sweating in the left half of
the body. Bilateral crepitations and
rhonchi. Other systems normal. BP 110/70
mm.Hg. Tracheostomy present.
INVESTIGATIONS : CT scan of the brain showed multiple
hypodense lesions in the left mid brain
hypothalmus and right basal ganglia
region. MRI of the brain showed the same
lesions. Ventricles normal. Hb 11.5 gms%,
ESR 130 mm/Hr., TC 11000/cmm, P 75%, E 2%,
L 23%,RBS 151 mgs%, urea 22 mgs/dl,
creatinine 0.6 mgs/dl.
TREATMENT : She was managed conservatively with physio-
therapy and antibiotics for her respiratory
infection. She gradually improved and the
tracheostomy tube was removed and the wound
healed. The left pupil returned to mormal
size and her eye movements became full
range. She continued to have a partial
ptosis of the left eye which was also im-
proving. Spasticity in the left sided
limbs returned to normal tone and right
sided limbs went into decorticate rigidi-
ty. She started opening eyes on call and had
sucking and snout reflexes. Repeat CT scan
of the brain showed resolution of the mid brain
and hypothalmic lesions.
She was discharged with advise to continue
further care and physiotherapy at home.
ADVICE : To continue physiotherapy as advised.
Care of Ryles tube and Foley's cantheter.
To nurse in waterbed.
Tab. Syndopa 275 mgs 1/2 tab. thrice daily
to continue.
Tab. Baclofen 10 mgs thrice daily to
continue.
Cap. Zevit one daily for 1 month.
To report regarding patient's progress
every two weeks and review after 2 months
in Neurosurgical OPD on any day from Monday
to Friday in Room No. 105 at 10.00 am.
Dr. D. Mukherjee
DIAGNOSIS : ? VIRAL ENCEPHALITIS WITH SECONDARY
DEMYLINATION
? ACUTE DEMYELINATING DISEASE.
SUMMARY OF PRESENT ILLNESS : Mrs.Sujatha aged 28 years was
---------------------------
admittted on 27.08.96 with rapid evolution of loss of
consciousness and fall in the toilet.
ON EXAMINATION : Patient is decerebrating and left pupil dilated,
GCS:5/15. Bilateral plantar extensor.
CT brain : Revealed suspicion of cerebral oedema.
CSF analysis was normal, CGF culture reported as klebsiella ?
contaminant .
Contrast CT done subsequently revealed multiple hypodense lesion
in both Internal capsules and mid brain.
Repeat CSF analysis was normal.
A provisional diagnosis of vasculitic disorder or vasculitis secondary
to viral encephalitis or acute demyelination.
She was put on Omnatax in view of CSF culture report, steroids,
antiviral drugs,beside supportive measures and Nursing care
Tracheostomy was done.
Investgations for vasculitis was normal.
After the general condition stabilised MRI brain and EEG were
done which are compatable with viral encephalitis though a acute
demyelination is not execluded.
At the time of discharge she was afebrile,reacting to painful
stimuli.Left IIIrd nerve palsy,decebrate rigidity .
She was discharged at request to continue treatment from a near by
hospital.
INVESTIGATIONS : 27.08.96 :
Haemoglobin : 12.9 gm%
Packed Cell Volume : 42%
WBC count : 13,300 /cmm
Platelet count : 3.4 lakhs/cmm
DIFFERENTIAL COUNT :
Neutrophil : 74%
Lymphocyte : 24%
Eosinophil : 1%
Monocyte : 1%
02.09.96 :
Haemoglobin : 13.0 gm%
Packed cell volume : 42%
WBC count : 21,500/cmm
Platelet count : 3.4 lakhs/cmm
DIFFERENTIAL COUNT :
Neutrophil : 94%
Lymphocyte : 5%
Monocyte : 1%
04.09.96 :
Haemoglobin : 12.5 gm%
Packed cell volume : 40%
WBC count : 17,900/cmm
Platelet count : 3.5 lakhs/cmm
DIFFERENTIAL COUNT :
Neutrophil : 87%
Lymphocytes : 12%
Eosinophil : 1%
Body fluids Report :
28.09.96 :
SPECIMEN : CSF FOR CELL COUNT :
Macroscopic appearence : Clear
Colour : Colourless
Total cell count : No WBCs seen
RBCs : Few RBCs seen
Body Fluids Report :
2.09.96 :
SPECIMEN : CSF FOR CELL COUNT :
Macroscopic appearence : Slightly turbid
Colour : Colourless
Total cell count : No WBCs seen
RBCs : Numerous RBCs seen
BIOCHEMISTRY :
27.08.96 :
Random Blood Sugar : 112 mg/dl
Urea : 18 mg/dl
Creatinine : 0.9 mg/dl
Sodium : 134 mEq/L
Potassium : 4.4 mEq/L
Chloride : 97 mEq/L
Bicarbonate : 26 mEq/L
BIOCHEMISTRY :
30.08.96 :
Random Blood Sugar : 157 mg/dl
Urea : 31 mg/dl
Creatinine : 1 mg/dl
Sodium : 140 mEq/L
Potassium : 3 mEq/L
Chloride : 99 mEq/L
Bicarbonate : 20 mEq/L
BIOCHEMISTRY :
04.09.96 :
Random Blood Sugar : 110 mg/dl
Urea : 72 mg/dl
Creatinine : 1.4 mg/dl
Sodium : 142 mEq/L
Potassium : 3.8 mEq/L
Chloride : 101 mEq/L
Bicarbonate : 22 mEq/L
BIOCHEMISTRY :
11.09.96 :
Random Blood Sugar : 114 mg/dl
Urea : 20 mg/dl
Creatinine : 1.1 mg/dl
Sodium : 132 mEq/L
Potassium : 3.1 mEq/L
Chloride : 97 mEq/L
Bicarbonate : 22 mEq/L
02.09.96 :
Sr. creatinine : 0.7 mg/dl
CSF sugar : 83 mg/dl
CSF protein : 10 mg/dl
CSF chloride : 772 mg/dl
07.09.96 :
Haemotology :
ESR : 85 mm/hr
07.09.96 :
L.E cells : Negative
09.09.96 :
LUPUS ANTI COAGULANT STUDY :
Lupus anti coagulant : absent
MICRO BOLOGY :
28.08.96 :
CSF : Occasional pus cells and no bacteria seen.
03.09.96 :
Blood : HSV Ab (Herpes simplex virus) : (IgG) : Negative.
02.09.96 :
CSF : No pus cells or bacteria seen
04.09.96 :
Urine : Moderate pus cells and many gram negative bacilli
seen.
05.09.96 :
E.T : Moderate pus cells and mixture of organisms seen.
28.08.96 :
CT scan of Brain : Features suggestive of Cerebral oedema
31.08.96 :
CT SCAN OF BRAIN : CONTRAST : Multiple non enhancing hypodense areas
involving mid brain, cerebral peduncle on the
left side, internal capsule and basal ganglia
bilaterally with cerebral edema - may suggest
possibility of demyelinating disorder.
Suggestion : MRI for further evaluation.
Blood : 09.09.96 :
Rheumatoid factor : Latex : Negative
VDRL : Non reactive
14.09.96 :
X-ray : Cervical spine AP and lateral : for perusal study
X-ray chest P.A : No obvious abnormality.
10.09.96 :
ECHO CARDIOGRAM REPORT : No regional wall motion abnormality.
Normal left ventrical function.
Trace pericardial effusion.
10.09.96 :
EEG gives evidence for a severe dysfunction involving
1. Hemispherical structures as well as sub cortical structures.
2. Involvement of white and gray matter.
None of the changes could be lateralised or localised.
MRI OF BRAIN WITH ANGIO : 10.09.96 :
Bilateral irregular patchy enhancement of the Thalami, posterior limb of
internal capsule,mid brain, occipital and temporal lobes and on right side
ependymal lining,cerebral peduncle and ponds.
ADVICE :
-------
3000 ml Ryles tube feeds.
Regular suction and tracheostomy tube care.
Water bed or alpha bed.
Back care.
Chest physiotherapy and limb physiotherapy.
Tab. Augmentin 375 mg 1 tab thrice daily for 3 days
Syp. Nootrophil 2 teasspoons thrice daily.
Tab. Syndopa 275 mg 1/2 thrice daily.
Tab. Baclon 10 mg thrice daily.
Clotrimazole ointment for local application over perineum.
Ciplox eye drops both eyes second hourly.
Soframycin eye drops both eyes thrice daily.
Asthalin nebuliser 2.5 mg 4 times a day if needed.
CT REPORT BRAIN : 26.09.96 :
----------------------------
PLAIN AND CONTRAST CT SCAN OF BRAIN :
-------------------------------------
Serial axial sections of the brain was studied from the base of skull
to the vertex before and after administration of IV contrast.
The study reveals multiple patchy hypodense non-enhancing lesions
in the left side of ponds, both thalami, internal capsules and both
occipital lobes.Rest of the brain parenchyma appears normal.
The ventricle is of normal size and is seen to be in position.The
basal cisterna are normal.Both the cerebello pontine angles are free.
Both the cerebral hemispheres do not show any abnormal appendations.
The sella and suprasellar regions are normal.The mid brain appers
normal.The orbits and cortents are normal.
Ventricles appear prominent.Both temporal horns are enlarged so
periventricular hypolucency noted.The basal ganglia are normal.
No shift of mid line structures is seen.
The cortical sulci are normal.The extra cerebral spaces are clear.
The cranial vault and extracranial soft tissue are within normal
limits.
IMPRESSION :
IN COMPARISON WITH PREVIOUS SCAN THERE APPEARS TO BE A
REDUCTION IN SIZE OF LESIONS ESPECIALLY THE BRAIN STEM
LESIONS.
