Description
- Abstract:
- Learning objectives: Cognitive impairment and delirium are presenting features of diverse disorders including electrolyte imbalance, infection, intoxication, stroke, seizure, and anemia. When approaching a patient with multiple causes, care must be taken to balance treatment between each etiology. Treatment for one cause may precipitate another, resulting in no significant change or exacerbation of the clinical picture. We report a case of a neurosarcoidosis flare with a contemporaneous seizure, pancytopenia, fulminant pneumonia, and phenytoin toxicity. Case report: A 37 year-old man with a history of neuro/pulmonary sarcoidosis presented with a four-week history of confusion, weakness, and visual impairment. Symptoms started following a complex-partial seizure contemporaneous to a likely neurosarcoidosis flare. On exam, he was afebrile, had horizontal nystagmus, and delerium. Cranial nerves were otherwise intact; strength was 3/5 in the left lower-extremity, 5/5 in all others. There was no photophobia, neck stiffness, or rash. He had pancytopenia with 2,600 WBC/uL, Hg 9.0 g/dL, Hct 28.1%, and 68,000 platelets/uL. Free phenytoin was toxic at 3.6 ug/mL. Chem-7 and head-CT were non-contributory. Phenytoin toxicity was considered a likely cause of nystagmus and stopped. Four days later, he developed a wet cough with fever, bandemia, and right lower-lobe opacity on chest x-ray. He was treated for healthcare-associated pneumonia with vancomycin and piperacillin/tazobactam. Pancytopenia worsened and was felt to be iatrogenic; most cytopenic drugs were stopped. Vancomycin was switched to meropenem due to its decreased thrombocytopenic properties. Neurology agreed to stop azathioprine, but valproic acid (VPA) was continued. Phenytoin returned to non-toxic range and cognitive function slowly improved. Neutropenia worsened, and the probable offending agent, VPA, was switched to levetiracetam. The patient then had resolution of pancytopenia, pneumonia, and cognitive impairment. Discussion: This patient presented with altered mental status (AMS) initially likely due to seizure and neurosarcoidosis. He was thus restarted on immunosuppressant medications including azathioprine. Ironically, this treatment of altered mental status secondary to neurosarcoidosis seemed to have contributed to his cognitive impairment vis a vis immune suppression which may have prolonged the course of pneumonia. VPA was initially not stopped due to fear of recurrent seizure. However, with prolongation of the pancytopenia, all drugs which caused immune suppression were stopped. VPA was switched to levetiracetam with subsequent recovery. Nonetheless, causality of his AMS is not definite as WHO criteria for certain causation was not met. Symptoms could have occurred secondary to a neurosarcoid flare, drug toxicity, or pneumonia. As hospitalization progressed, each etiologic association seemed more probable than others at times. Care must be taken when balancing treatments or assigning mono-causality of AMS.
- Notes:
- Scholarly concentration: Advocacy and Activism
- Presented at: Society of General Internal Medicine-NE Conference, February 2013
- Peer-reviewed
Citation
Hussain, Rashid, Gentilesco, Bethany, and Feller, Edward,
"Altered mental status in the setting of anemia, pneumonia, and a neurosarcoidosis flare"
(2013).
Warren Alpert Medical School of Brown University Scholarly Concentrations Program Gallery of Scholarly Work.
Brown Digital Repository. Brown University Library.
https://repository.library.brown.edu/studio/item/bdr:659449/
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Warren Alpert Medical School of Brown University Scholarly Concentrations Program Gallery of Scholarly Work
The Scholarly Concentrations Program is an elective program through which Warren Alpert Medical School students may elect to pursue a course of study beyond that of the conventional medical education curriculum....