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Week 22

 

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Quiz 22 Context:

In the early fall of the year, you are asked to see a 75-year-old male in consultation for fevers and mental status changes. This patient originally presented 10 days prior with an acute dissection of the abdominal aorta. His management at that time included emergent surgery and multiple blood transfusions. Following this the patient has been managed in the intensive care unit. 4 days ago he had been successfully weaned from the ventilator and off all pressors. 3 days ago the patient developed low grade fevers, headaches, gastrointestinal complaints, and myalgias. Blood cultures and chest X-ray were negative. Over the past 48 hours the patient has developed confusion and weakness; he became agitated and combative and was re-intubated for airway protection. The patient continued to exhibit deterioration in mental status as well as progressive and demonstrable weakness; he was noted to have evidence suggestive of an axonal polyneuropathy on electromyogram testing.

Past medical history is most significant for vasculitis. The patient has been maintained on corticosteroids for the same.

Physical examination reveals a male patient, intubated, on mechanical ventilatory support. Temperature is 38.5. Heart rate 90 bpm. Blood pressure 100/60 without pressor agents. The examination is difficult due to the patient's condition, however the neurologic examination is suggestive of a diffuse flaccid paralysis. The remainder of the examination is nonspecific.

An MRI of the head and spine are performed; significant findings are shown above.

This history, examination, and MRI data are most consistent with which of the following possibilities:

  1. Acute hemorrhagic stroke
  2. Toxic shock syndrome
  3. Cushing's Syndrome
  4. Meningoencephalitis
  5. Central pontine myelinolysis

 

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Center for Continuing Education | 9500 Euclid Avenue, KK31, Cleveland, OH 44195