Case 2Case 248 yr Female48 yr Female

Past H/O ofPast H/O of

AsthmaAsthma

Chronic Arthritis- on NSAIDs & HydroxychloroquineChronic Arthritis- on NSAIDs & Hydroxychloroquine

Not Known HTNNot Known HTN

Non DiabeticNon Diabetic

Chief ComplaintsChief Complaints

Fever for 6 daysFever for 6 daysNeck Gland swelling few days agoNeck Gland swelling few days ago

Nausea & vomiting 2 daysNausea & vomiting 2 days

Generalized Malaise & Myalgia for last Generalized Malaise & Myalgia for last few weeks few weeks

Clinical ExaminationClinical Examination

Alert, orientedAlert, oriented

Pyrexial Pyrexial

No rashNo rash

Noted Hypertensive 150/90Noted Hypertensive 150/90

No cervical or axillary No cervical or axillary lymphadenopathy.lymphadenopathy.

Chest clear Abd- normal.Chest clear Abd- normal.

No Focal Neurological deficit elicitedNo Focal Neurological deficit elicited

InvestigationsInvestigationsHb- 8.6Hb- 8.6 TC- 8420TC- 8420 ESR-73 ESR-73 PLT- NPLT- N

Ur- 245Ur- 245 Cr- 5.84Cr- 5.84 K-5.7K-5.7 Na-134 Na-134

Ptime- 16.9/11.9Ptime- 16.9/11.9 INR- 1.54INR- 1.54

TB- 4.7 con3.4TB- 4.7 con3.4 SGOT-139 SGPT-167SGOT-139 SGPT-167 ALP-949 ALP-949

TP-6.0TP-6.0 ALB-1.9ALB-1.9 GLB-4.1GLB-4.1

CoCa- 9.06CoCa- 9.06 Urate- 14.2Urate- 14.2

Malaria dual Ag- NegativeMalaria dual Ag- Negative

Dengue- Negative.Dengue- Negative.

Leptospira IgG & IgM- NegativeLeptospira IgG & IgM- Negative

Widal Test- NegativeWidal Test- Negative

HBsAg, HCV, HIV- Non reactiveHBsAg, HCV, HIV- Non reactive

HAV- IgM Non reactiveHAV- IgM Non reactive

HEV- IgM REACTIVEHEV- IgM REACTIVE

ANF, ANCA- NegativeANF, ANCA- Negative

Serum Electrophresis- No Monoclonal Band

USS AbdomenUSS Abdomen

Mild HepatomegalyMild Hepatomegaly

Spleenomegaly with Dialated Spleenic VienSpleenomegaly with Dialated Spleenic Vien

Kidneys- Loss of cortico-medullary Kidneys- Loss of cortico-medullary differentiation likely due to CKD. differentiation likely due to CKD.

Initial DiagnosisInitial Diagnosis

Acute on Chronic Liver FailureAcute on Chronic Liver Failure

Chronic Liver DiseaseChronic Liver Disease

Altered Ptime, Altered LFT & Albumin:Globulin ratio Altered Ptime, Altered LFT & Albumin:Globulin ratio reversal, Hepatospleenomegaly, Dilated Spleenic Vienreversal, Hepatospleenomegaly, Dilated Spleenic Vien

Acute Hepatitis EAcute Hepatitis E

Chronic Kidney DiseaseChronic Kidney DiseaseMost likely secondary to Hypertension & Most likely secondary to Hypertension &

Chronic NSAID use.Chronic NSAID use.

Initial ManagementInitial Management

Blood Pressure ControlBlood Pressure Control

Anti HyperKalemic TreatmentAnti HyperKalemic Treatment

Broad Spectrum Antibiotic: Broad Spectrum Antibiotic:

Cefepime/TazobactumCefepime/Tazobactum

On the 3On the 3rdrd day of her admission, the day of her admission, the patient became very restless, patient became very restless, disoriented with increasing lethargy disoriented with increasing lethargy and almost bed bound.and almost bed bound.

Neurological assesment couldnot be Neurological assesment couldnot be done as the pt was very agitated & done as the pt was very agitated & uncooperativeuncooperative

A diagnosis of Stage 2 Hepatic A diagnosis of Stage 2 Hepatic Encephalopathy secondary to HEV Encephalopathy secondary to HEV super infection, decompensating the super infection, decompensating the underlying CLD was made.underlying CLD was made.

ManagementManagement

Arterial Ammonia checked(81) &Arterial Ammonia checked(81) &Anti Encephalopathic measures started.Anti Encephalopathic measures started.

However pt did not respond & her condition However pt did not respond & her condition worsened becoming pyrexial & tachycardic, worsened becoming pyrexial & tachycardic, she needed Intubation for Airway she needed Intubation for Airway protection.protection.

Neurological Examination revealed new onset Neurological Examination revealed new onset UMN signs UMN signs Exaggerated Knee Jerks B/L & ankle clonusExaggerated Knee Jerks B/L & ankle clonusPlanters were Equivocal.Planters were Equivocal.

CT BrainCT Brain

CT BrainCT Brain

ABGs revealed- ABGs revealed- Metabolic Acidosis Metabolic Acidosis

The Metabolic Acidosis was thought to The Metabolic Acidosis was thought to be due to developing sepsis.be due to developing sepsis.

Lactate was Normal.Lactate was Normal.

Escalation of ABx to Imipenem & Escalation of ABx to Imipenem & LinezolidLinezolid

CSF ExaminationCSF Examination

CSF sample sent for HSV detectionCSF sample sent for HSV detection

Pt started on Acyclovir 500mg BD.Pt started on Acyclovir 500mg BD.

Recovery started within 48 hours, Recovery started within 48 hours, Presently pt is completely coherent, Presently pt is completely coherent, Alert, oriented with almost fully Alert, oriented with almost fully recovery.recovery.

Her LFT has normalised apart from an Her LFT has normalised apart from an isolated high ALP.isolated high ALP.

Cr has lowered to 4.1. Cr has lowered to 4.1.

Not Herpes EncephalitisNot Herpes Encephalitis

MRI ScanMRI Scan

So what is the So what is the Diagnosis & what Diagnosis & what has made the has made the patient Well? patient Well?

Thank YouThank You