Early morning at 8am, a patient was pushed into red zone. A 60 year-old man, no known comorbids, has history of fever and vomiting for 1 day, then noted became unconscious this morning. GCS upon arrival was only 3/15. Very limited history available. Family members claimed he has no history of recent travelling/ river swimming/ jungle trekking.
Clinically, his BP was lowish, having high grade temp, normal SPO2, ABG acidotic. Pupils, cardiovascular, respiratory, abdominal examination are unremarkable. Noted he has got generalized purpuric rashes, slight jaundice and no urine output. Capillary blood sugar "low".
So the clinical picture seems to be severe sepsis with multi-organ failure. But what is the cause of sepsis? And the hypoglycemia seems unusual in a sepsis case. Then I was informed by the nurse, the sugar after Dextrose 50% 50cc bolus, only increased to 1.5mmol/L, still low.
Strange.
Think.
Wait, oh I think I got the diagnosis!
Some key treatment was given. He was sent to ICU.
Later the medical MO and physician also agree with the diagnosis.
What could be the most likely diagnosis?=)
(Answer's in my comment. Think before you open it!)
Wednesday, September 24, 2008
Interesting Case!
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20 comments:
The most likely diagnosis is Waterhouse-Friderichsens's syndrome. It's a condition where rapidly deteriorating meningococcal sepsis causing bilateral adrenal cortex hemorrage.
You might argue that so limited information was given, but that's what will happen in real life, you need to come out with the diagnosis before all blood/imagining results are back. Right?=)
you gave the clear hint already... aiyak, no fun one!
:-)
omg what is that!!! i heard of it before but have no idea what is it... =(
i thought and thought b4 i open the comments page.. but the answer that appeared also saya tak faham..
i must go study more!!
shawn: Yalo i also think that the hint is little bit obvious..ok modified it dy heheheh
zzzyun: No worries! Nice try!=D
A tough one...huh...
whoa! good.
Interesting.
δΈιε！
pricewaterhousecoopers i know la. Ha ha..damn good la u all. respect respect.
wohkay. sounds real serious
wa.. like speaking alien language to me.. =.="
really interesting!
erm, the purpuric rashes pointed to meningococcal infection and i thought it was meningitis.
haha, didn't notice that there weren't any meningeal syndrome at all
swein: Huh? Ya la it's meningitis..fever, vomiting, droppin GCS, rapid deterioration, purpuric rashes..it pointed towards a meningococcal sepsis=)
Nice case Darren, keep posting more real life cases :)
i was thinking of Addisonian Crisis.... coz a patient came to to HUKM last night.... similar presentation... not responsive, GCS 3/15.. hypoglycemia, hypotension, in shock.. got hyperpigmentation... electrolytes imbalance.. she had fever, suspected infection and a septic workout was done for her too...
hmm.... how to differentiate them?
Shinyin: Ya you're right that it's Addisonian picture..as i said, WhF syndrome is meningococcal sepsis with bilateral adrenal cortex hemorrhage causing acute insufficiency..hence the presentation.
To make it simpler, yes in this case you're seeing an addisonian case and the underlying cause is? meningococcal infection and so the full diagnosis would be WhF syndrome!;)
Wow, that's crazy man. They should really try to do something to fix that.
really an eye opener for me.
- Robson
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