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A confused patient with deranged liver function tests
  1. Harry Tucker1,
  2. Zain Masood1,
  3. Suresh K Chhetri1,2
  1. 1Department of Neurology, Royal Preston Hospital, Lancashire Teaching Hospitals NHF Foundation Trust, Preston PR2 9HT, UK
  2. 2University of Central Lancashire, Lancaster, Lancashire PR1 2HE, UK
  1. Correspondence to Dr Harry Tucker, Department of Neurology, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston PR2 9HT, UK; Harry.tucker{at}lthtr.nhs.uk

http://dx.doi.org/10.1136/practneurol-2020-002594

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    Clinical case

    A 31-year-old right-handed man was transferred by ambulance after falling out of bed. His wife reported that he was agitated, not moving his left side, appeared ‘blue in the face’ and complained that he could not see properly. He had a history of seronegative inflammatory arthritis and keratitis. On arrival at the emergency department, he was significantly agitated and required anaesthetic support for sedation and intubation.

    Further collateral history found that in the 10 days before admission, he had reported increasing joint pain and swelling, neck stiffness and general malaise. His regular medications were paracetamol and naproxen. Combination therapy for his seronegative inflammatory arthritis in the form of methotrexate and sulfasalazine had been stopped 2 weeks before due to routine blood monitoring identifying deranged liver function tests.

    On neurological examination, he was encephalopathic and could not follow commands. He had normal pupillary responses and funduscopic appearances. There was no gaze preference, facial weakness or meningism. His muscle tone was normal, and strength testing in the context of poor cooperation found no lateralising weakness. Limb reflexes were symmetrically present, and plantar responses were bilaterally extensor.

    What is the most likely clinical syndrome?

    We suspected that he had experienced a generalised seizure, given the description of central cyanosis and altered mental state with agitation. The initial witness account of left-sided weakness suggested either a right hemispheric lesion or a Todd’s phenomenon.

    The prodromal symptoms of neck stiffness and altered mental state with suspected seizure made meningoencephalitis the most likely diagnosis.

    We started ceftriaxone and acyclovir promptly in the emergency department, …

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    Footnotes

    • Twitter Harry Tucker @DrHTucks

    • Contributors HT performed the literature search and wrote the manuscript. ZM was the first attending clinician in the patient’s caseand reviewed the manuscript. SC was the responsible clinician for patient and reviewed the manuscript prior to submission.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Consent obtained directly from patient(s).

    • Provenance and peer review Not commissioned. Externally reviewed by Brendan Mclean, Truro, UK.

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