22

41 YEAR OLD FEMALE  Patient was brought with complaints of 2 episodes of involuntary movements of

upper and lower limbs and hemoptysis .History of present illness :- Patient was apparently

asymptomatic till 5 am then she developed sudden onset of movements of both upper and lower

limbs at 5am in the morning which lasted for about 4-5mins , not associated with any trigger, no aura

and the patient was confused after the episode she had an other similar episode while bringing to the

hospital.She had two similar episodes at the hospital.Sequence of events :- 13 years ago she

developed low back ache and generalised weakness started for which she went to local hospital.Then

during the investigations was found to be having soft tissue overgrowth,(as said by attenders ,no

documentation)and need to get operated, during routine investigations creatinine was elevated, then

she was started on conservative management .(Sod bicarb,Shelcal,Omeprazole,Iron folate)Since

then ,she is on routine followup with hemogram and serum creatinine levels,and her baseline

creatinine levels were 3.2mg/dL.In june 2022,she developed fever and productive cough associated

with SOB for which CT chest was done,showing peripheral ground glass opacities,and septal

thickening was notedand few days later , she developed swelling of both lower limbs till the level of

ankles,which were insidious in onset and gradually progressiveThen underwent dialysis for the first

time through right IJV line,for 4 hours,and was on conservative management.3 months later, she

developed fluid filled bleb, on one finger and then over all the 10 fingers of hand in 10 days ,some of

which ruptured on their own and some were pricked by the patient.She developed eroding nails and

distorted nails , hyperpigmented macules over the face and itching over the palms,and low grade

fever associated with loss of apetite and alopecia.Ulcers over palms , pulp of fingers associated with

burning sensation With autoimmune etiology suspicion, she was investigated further and was ANA profile and was tested Positive for Anti Ro 52and SSA/Ro

60++,and SSB/La+.2days back she developed sudden onset developed movements of UL and

lowerlimbs, for 3-4minutess, associated with blood from mouth,and there is a brief period of LOC

.similar episode one at 6:00 am, and then 2 similar episodes after they came here at 8:00am.At

presentation her blood pressure was 170/110MMHGCourse in hospital:- 46years old female came

with complaints of Hemoptysis and involuntary moments of upperlimb and lowerlimb 4 episodes since

morning, and her GCS at presentation being E1v1m1,pupillary reflex and corneal reflex was

present,At presentation her blood pressure was 170/110 mmhg ,inj lorazepam was given, later

leviteracetam was given and when her seizures weren’t controlled then sodium valproate was given

She later then had continuous episodes of seizures lasting for more than 45 minutes . In view of

respiratory distress ( sats 60 ),and uncontrollable recurrent seizures she was sedated with IV

MIDAZOLAM and intubated. Post intubation, she had cardiac arrest ( no central pulses palpable ) 2

cycles of CPR done ROSC was achieved and post CPR monitor showed monomorphic VT and 2

times 200 J of DC shock was given and then it reverted to sinus tachycardia. Course in hospital :-

After returning to normal rythm Post cpr day 1 :- pt is on mechanical ventilator ACMV/VC mode with

fio2 of 40 per peep :- 5 cms h20 tidal volume -450ml and t inspiratory -1.5 and started on iv antibiotics

and patient is on sedation with midazolam cont iv infusion and her pupils are dilated and non reactive

to light with dolls eye reflex: eyes moving on same side And mri brain was done and it showed -?

PRESS ? ODS ?uremic encephalopathy Upper limb reflexes are present on left side and lower limb

reflexes are absent and plantars are mute and derma referal was taken for the blebs over hand and

was diagnosed as ?bullous phemphigoid ? Friction induced blisters and ophthalmology opinion was taken to rule out rasied icp but no raised ict features are seen on fundoscopy and

nephrology opinion was taken i/v/o raised renal parameters and they advised for hemodyalsis and

one session was done on 5/1/23 on next day midazolam infusion was stopped to plan for extubation

but as patient is not taking breaths spontaneously extubation was not done and i/v/o raised pt aptt inr

vit k was given and neurology opinion was taken and they advised for EEG and lumbar puncture was

done and pulmonolgy opinion was taken for resuming ATT and advise followed and on D3 of

intubation patient is on ACMV/Vc mode with rr :- 14cpm fio2 :-45 peep :- 5 VT :- 450ml tinsp :- 1.9

and she developed ulceration over the sacral region ? Bed sore and surgery opinion was taken and

was diagnosed as having a soft tissue based non mobile and non blanchable ulcer with partial

thickness skin loss and late superficial ulcer ? Grade 2 bed sore and reflexes of b/l UL and LL were

absent and pupils decreased in size and reacting to lights and dolls eye moving to same side and

GCS :- E1VTM1 and antifungal tab voricanzole was started (as BAL showed aspergillosis ) on day 4

of intubation pt was taken for second session of hemodialysis on 8/1/23 and anesthesia opinion was

taken for weaning of from ventulator but as the weaning of criteria was not met and as patient is

tachypnic patient is restarted on midazolam 30mg and fentanyl 200mcg as per anesthetist advise and

patient is shifted to SIMV mode on day 5 of intubation sedation was stopped at 8:00 am as patient is

taking spontaneous breaths and inview of deranged Pt,APTT and INR,4 FFP transfusions were

done,and as the patient blood pressure is persistently high,she was started on calcium channel

blocker(Tab.Amlong 10mg), and as the patient pulse rate is high,was started on Beta

blocker,(Tab.met Xl)tracheostomy was done on 11/1/23 and post tracheostomy spontaneous

breathing trial was done and the patient was started on T piece ventilation but

as the Bloodgas analysis showed metabolic acidosis with respiratory alkalosis,another episode of

dialysis was done on 13/1/23 ,and in view of increasing counts,started on Inj.vancomycin according to

renal clearance,and later as the oxygen wasn’t maintaining patient was shifted to CPAP and

spontaneous breath trail was performed everyday, OMFS referral was taken for her tongue bite and

the orders were followed,the GCS being E2V1M4,and the gag and brain stem reflexes were

intact,and review mri scan was done on 13/1/23,to rule out any hypoxic injury to brain,and the MRI

showed mild hypoxic ischemic encephalopathy changes in both cerebral hemishperes and basal

ganglia,and for thromboprophylaxis DVT stockings were placed and advised for passive

Physiotherapy,and patient is on conservative management,and she was managed with Intermittent

CPAP With T piece support and the GCS today on 16-01-2023,being E2VtM4 ,patient attenders have

been explained about the condition of the patient,and the prognosis of the patient in thier own

understandable language,even explaining the risk of the patient condition after taking home,but the

attenders dont want to stay and want to leave gainst medical advice.

Investigation

mri done on 3/1/23

impression :multiple areas of flair/t2 hyperintense signal in b/l subcortical white matter in both cerebral

hemispheres -suggestive of posterior reversible encephalopathy syndrome t2/flair hyperintensive signal seen in central pons with no obvious restricted diffusion- likely

suggestive of osmotic demylenation syndrome

mri done on 13/1/23:

impression

posterior reversible encephalopathy syndrome

uremic encephalopathy

osmotic demylenation syndrome

thereis diffusion restriction in corpus callosum and rt parietal lobe likely hypoxic ischemic

encephalopathy

evidence of soft tissue swelling in occipital predominantly on left side

2d ECHO:

03-01-2023

Tachycardia

No RWMA Mild LVH(1.18cms)

Moderate TR with PAH(53mm of hg)

Mild AR no MR

Sclerotic Thickened AV

EF = 58% Good LV systolic function

Diastolic dysfunction No PE

IVC size (1.09cms) collapsing.

12-01-2023

No RWMA Mild LVH(1.18cms)

Trivial TR+/AR+ no MR

Sclerotic Thickened AV

No AS/MS

EF = 58% Good LV systolic function

Diastolic dysfunction No PE/PAH

IVC size (1.10cms) collapsing.

CULTURE AND SENSITIVITY

05-01-2023

Sputum for C/S : Normal Oropharyngeal Flora grown.

Blood C/S : No Growthafter 24hrs of aerobic incubation

Urine for C/S : No growth

06-01-2023 ET C/S : Normal oral flora grown.

ET secretions for CBNAAT : No MTB Detected.

09-01-2023

CSF for C/S : No growth

ET secretions : Oral flora seen

Pus swab for C/S : Skin commensals grown.

12-01-2023

Blood C/S : Enterococci species isolated

Urine C/S : Enterococci species isolated

Diagnosis 1. Hypoxic Ischemic Encephalopathy (post CPR status) 2. Generalised Status Epilepticus secondary to autoimmune vasculitis - PRES/Septic/ Uremic Encephalopathy 3. Prerenal AKIon CKD on Hemodialysis 4. Urinary tract infection 5. Antisynthetase syndrome 6. Pulmonary TB 7. ? Invasive Aspergillosis 8. Post Tracheostomy 9. Grade 3 bedsore

Treatment Given(Enter only Generic Name)

1. RT feeds 50 ml water with protein powder 2nd hrly , 100ml milk : 4th hrly,

2. Inj Meropenem 500mg/IV/BD

3. Inj Vancomycin 1gm /IV/OD4. Inj Pantop 40mg IV/OD 5. Inj Zofer 4m IV/OD6. Inj Neomol 100ml /IV

/SOS7. Inj Vit K 1 amp in 100 ml NS/IV/OD 8. Inj Levipil 500mg in 100 ml NS/IV/BD

10. Inj EPO 4000 IU /SC/ twice weekly[given on 15-01-2023]11. Tab Voriconazole 100mg RT/BD12.

Tab Isoniazid(245mg) + Tab Rifampicin (490mg) RT once daily

13.Tab Pyrazinamide(1225mg) + Tab Ethambutol(735mg) RT alternate day14.Tab Dolo 650mg /RT/

6th hrly 15.Tab Atorvas 20mg /RT/H/s

16.Tab Amlong 10mg/RT/OD

17. Tab Nodosis 500mg /RT/BD 18. Syrup Potklor 15ml/RT/ TID

19. Nebulisation with Mucomist and Ipravent 6th hrly with chest physiotherapy20. DVT stocking 21.

Airbed22. ABG monitored 6th hourly 23. Grbs monitored 4th hourly24. E/D Lubrex 0/0/0/0 both eyes

4times/ day25. E/D Moxiflox 0/0/0/0 both eyes 4times/ day26. Fudic cream L/A /BD/1week27. Zyte

gel for L/A to lower lips 28. Neosporin powder L/A for bed sore29. Both upper limbs elevation30.

Vitals monitored 2nd hrly

31.Tracheostomy suctioning done 2nd hrly with tracheostomy dressing done daily

32. Hemodialysis done on 05-01-2023, 08-01-2023 and 13-01-2023.

Advice at Discharge

Pateint's attenders have been clearly explained about the patient condition and the need for hospital

stay for tracheostomy careand the need for bedsore management and cardiac monitoring in their own

understandable language and the riskof death also has been explained but the patient's attenders are

not willing for further hospital stay and management and want to leave against medical advice