A 26 year old lady presents from home confused with a low-grade fever. Her blood pressure is 160/100 mm Hg.  She has no gross motor deficits. Ten days ago she had an emergency termination of pregnancy for an intrauterine death that was complicated  by  disseminated  intravascular   coagulation.     She  was  32  weeks gestation and had been on labetalol for a pregnancy-induced hypertension.

Her   discharge   medications   included   paracetamol,   tramadol   and   a  selective serotonin reuptake inhibitor.  She has a 6-year history of uncomplicated Hepatitis C.

27.1.   List the differential diagnoses for her confusion and temperature.

27.2.   Outline your approach to establishing the diagnosis.

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College Answer

27.1.   List the differential diagnoses for her confusion and temperature.

Pregnancy related: Eclampsia / preeclampsia / HELLP, Retained products with sepsis, Sheehan’s syndrome / pituitary apoplexy, Posterior reversible encephalopathy syndrome (PRES), Hypertensive encephalopathy

Primary  neurological:  Infection  (meningitis  /  encephalitis),  cerebral  venous  thrombosis, seizure disorder, other cerebro-vascular

Metabolic: Sodium (hypo/hyper), Glucose (hypo/hyper), Renal failure, Liver failure (HCV / Paracetamol / Antidepressants),

Drugs: Accidental / intentional overdose, drug reactions (serotonin syndrome) Infection: Uterine, intracranial, other (renal, chest etc)

27.2.   Outline your approach to establishing the diagnosis.

History:  Collateral,  Pregnancy  issues,  Ongoing  blood  loss,  bleeding  /  bruising,  drug ingestions, mood / affect, headaches

Examination:  BP,  uterine  size  /  discharge,  oedema,  meningism,  neurological  (tone, reflexes, symmetry), chronic liver disease

Investigations: 
FBC: Bleeding, platelets, WCC
UEC: urea / creatinine, Na, Ca, glucose
Coagulation: DIC, INR for CLD
LFT / Ammonia: hepatic encephalopathy, drug reactions
ABG: hypoxia / hypercarbia
Urinary drug screen / paracetamol level
Sepsis Screen, CT head +/- LP

Discussion

The college have presented a high quality systematic answer.

One can generate no better differentials for this decreased level of consciousness. They even included cerebral venous thrombosis.

The history is rich in possibilities.

Vascular causes:

  • cerebral venous thrombosis
  • PRES
  • Hypertensive encephalopathy

Infectious causes

  • Sepsis due to retained products
  • Meningitis / encephalitis

Neurological causes

  • Seizures (potentiated by tramadol)
  • Serotonin syndrome

Drug related

  • Intoxication

Autoimmune

  • Cerebral vasculitis

Traumatic

  • Head injury

Endocrine/metabolic/electrolyte related

  • Hyponatremia
  • Hypoglycaemia
  • Hepatic encephalopathy (HELLP)
  • Uremia

A genric approach to the unconscious patient in the ICU  is available locally.