AMS after Shingles

UNFINISHED CASE: COME BACK LATER 

Scroll to bottom for case answer and E-meducation 

History:

• A 54-year-old female on acyclovir for 1 week for V2 facial shingles is brought to the ED by family for confusion and excessive sleepiness.
• She denies any fever or headache but did vomit once

Exam:

• Vital signs were normal.
• Physical exam was normal except for a crusted Zostiform rash to the right face and lack of animation.
• She is oriented x 4 but slow to respond

Testing:

• Basic labs were normal
• Brain MRI is shown below

QUESTIONS:

1. What does the case image image show?  (click two times to enlarge)
2. What should you do next?  
3. Where can I get a quick refresher on this topic?  See highlighted area below

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWERS:

1. What does the case image image show?  Brain MRI w/o contrast showed: Bilateral thalamic and basal ganglia edema c/w encephalitis. Marked congestion of deep venous structures.  Brain MRI with contrast showed:  shelf thrombosis and occlusion of the straight and left transverse sinuses. Bilateral thalamic and basal ganglia edema suspicious for venous occlusion.  Brain MRV showed: Left transverse sinus and straight sinus thrombosis and occlusion.
2. What should you do next?  First an LP which was done and showed slightly xanthochromic CSF with the following cell counts:  580 RBC, 22 WBC (74% PMN’s).  Next, call a ID, give IV acyclovir and admit the patient
3. Where can I get a quick refresher on this topic?  See highlighted area below

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E-meducation for medical topic of this case: Read the yellow highlighted area of the page-shot below from our #1 title, the Emergency Medicine 1-Minute Consult Pocketbook

RELATED ARTICLES:

1. https://www.ncbi.nlm.nih.gov/pubmed/29159001
2. Clinical analysis and misdiagnosis of cerebral venous thrombosis

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