CASE PRESENTATION ON ACUTE MENINGOENCEPHALITISWITH SEIZURES

Presented byNIKHIL SINGH

M.PHARMNIPER,HAJIPUR

INTRODUCTION

ENCEPHALITIS• Encephalitis is an acute inflammatory process affecting

the brain• Viral infection is the most common and important cause,

with over 100 viruses implicated worldwideSymptoms

• Fever• Headache• Behavioral changes• Altered level of consciousness• Seizures

Causes of Viral Encephalitis

• Herpes viruses – HSV-1, HSV-2, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, human herpes virus 6

• Adenoviruses• Influenza A• Enteroviruses, poliovirus• Measles, mumps, and rubella viruses• Rabies• Arboviruses – examples: Japanese encephalitis; St. Louis

encephalitis virus; West Nile encephalitis virus; Eastern, Western and Venzuelan equine encephalitis virus; tick borne encephalitis virus

• Bunya viruses – examples: La Crosse strain of California virus• Reoviruses – example: Colorado tick fever virus• Arenaviruses – example: lymphocytic choriomeningitis virus

MENINGOENCEPHALITIS• MENINGOENCEPHALITIS:- Inflammation in brain

membrane.Brain is covered by three layers1)Pia-matter (innermost layer)2)Arachnoid-matter (middle layer)3)Dura-matter (outer layer)

OBJECTIVE FINDINGS• AGE : 9 MONTHS• SEX : MALE• WEIGHT : 7Kg• BP : 110/70mm Hg• HR : 129/min• Case Reference: IGIMS, Patna, Bihar

CHIEF COMPLAINTS

1. FEVER × 2 DAYS

2. SEIZURES × 4 – 5 EPISODES

INVESTIGATION NORMAL RANGE D1 D3 D7 D14

Hb 13-18 gm% 8.6 8.5 7.7 14.7

TLC 4.0-11.0 thou/µl 13.8 13.3 11.7 5.8

NEUTRO. 50-70% 70 70 70 70

LYMPHO. 20-45% 21 21 23 23

MONO. 2-10% 4 4 2 2

EOSINO. 1-6% 2 2 2 2

THROMBO. 1.5-4.0 Lakh/µL 2.74 2.74 3.85 3.85

Na+ 135-145mEq/L 138 143 136 136

K+ 3.5-5.2mEq/L 5.1 5.2 4.0 4.0

Cl- 95-105mEq/L 105 103 105 105

CREATININE 0.6-1.2 mg% 1.1 0.3 0.6 0.6

UREA 10-50 mg% 24 13 12 12

LABORATORY INVESTIGATIONS(1)

INVESTIGATION NORMAL RANGE

D1 D3 D7 D14

Ca+2 8.6-10.2 mg/dl 8.8 6.3 6.8 9.2

SGOT 2 – 40 U/L 44 42 44 85

SGPT 2 – 41 U/L 44 40 43 72

ALP 40 – 129 U/L 122 122 122 122

Billrubin D 0.0 – 0.3 mg% 0.3 0.3 0.3 0.3

Billrubin T 0.2 – 1 mg/dl 0.7 0.7 0.7 0.7

Total protein 6.4 – 8.3 gm/dl 5.1 4 4.1 6.4

Albumin 3.4 – 4.8 gm/dl 2.7 2.6 1.8 3.4

Globulin 2 – 4.1 gm/dl 2.4 2.3 2.3 3.1

LABORATORY INVESTIGATIONS(2)

DIAGNOSIS

ACUTE MENINGOENCEPHALITIS SEIZURES(GTCS)

ROA DRUG D1 2 3 4 5 6 7 8 9 10 11 12 13

I.V PHENYTOIN(72 mg/OD)

I.V Na.VALPROATE (90 mg/BD)

I.V PHENOBARBITONE(45 mg/OD)

P.O PHENYTOIN(30 mg/OD)

P.O Na.VALPROATE (250 mg/TID)

I.V CEFTRIAXONE (450 mg/BD)

I.V ACYCLOVIR(90 mg/TID)

MEDICATION CHART(1)

ROA DRUG D1 2 3 4 5 6 7 8 9 10 11 12 13

I.V PIPERICILLIN(4 gm) +TAZOBACTAM(0.5 gm)-I.MOD

I.V VANCOMYCIN(180 mg/QID)

I.V AMIKACIN(150 mg/OD)

I.V PANTOPRAZOLE(9 mg/BD)

P.O SYP.ACETAMINOPHEN(125 mg/QID)

P.O SYP.CALCIMAX(5 ml/OD)

P.O SYP.LACTULOSE(15 ml/OD)

MEDICATION CHART(2)

PHARMACEUTICAL ISSUES

1.CONTRAINDICATION:CEFTRIAXONE is contraindicated in patient with hypoalbuminemia

• MANAGEMENT- Ceftriaxone can be substituted with cefotaxime(50 mg/kg/day)

- (REF: NICE GUIDE LINES-2006)

PHARMACEUTICAL ISSUES

2.CONTRAINDICATION:-Pantoprazole is contraindicated in children

• MANAGEMENT -Pantoprazole can be substituted with

Omeprazole(6mg/day)

(Reference: BNF for children-2006)

2.INAPPROPRIATE DOSE :

DRUG REC. DOSE/FREQ. PRES. DOSE/FREQ.

AMIKACIN 105mg/day 150mg/day

VANCOMYCIN 315mg/day 600mg/day

CEFTRIAXONE 720mg/day 900mg/day

PHENYTOIN 45mg/day 30mg/day

LACTULOSE 4mg/day 12mg/day

(Reference:BNF for children-2006)

3.INAPPROPRIATE FREQUENCY :

DRUG REC. FREQ. PRES. FREQ.

Na. VALPROATE o. d. b. d.

(Reference:BNF for children-2006)

THANK U

THANK U

PHENYTOIN

• REC. DOSE• 2.5mg × 2 ×7Kg= 35mg/day

• PRES. DOSE .• 30 mg/day

AMIKACIN• REC.DOSE.7.5mg×2×7kg=105mg/day• PRES.DOSE=150mg/day

VANCOMYCIN• REC.DOSE. 15mg×7kg×3=315mg/day• PRES.DOSE.600mg/day

CALCIMAX(5ml):

1. CALCIUM CARBONATE :625 mg2. VITAMINE D3 :200 IU3. MAGNESIUM HYDROXIDE :180 mg4. ZINC GLUCONATE :14 mg