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86M HTN DM CVA ORBITAL CELLULITIS SEPSIS

 



86 year male born in a middle class family of 7 children, was an elder son, did not go to school and took upon family responsibility at a very young age and started fish business. He used to travel often inter country for his business. Can speak Hindi and Telugu. 

Childhood was pleasant, married at young age and had five sons. His parents expired due to old age. 

Patient started consuming alcohol (beer) during travelling occasionally and also started smoking.

16 years ago patient had complains of lower back pain and decreased urine output, went to Kamineni Hyderabad and was diagnosed as renal calculi and operated for same. 

Two years later he returned home from work, had dinner and went to bed. Early in the morning he felt tiredness and struggled to wake up, later he observed he had right upper and lower limb weakness and slurring of speech. Patient went to local hospital and was diagnosed as right hemiparesis . At the same time he was also diagnosed with hypertension and diabetes. After he got discharged he started herbal medication and was on it for 5 years. Patient felt better and was able to do his own chores. He used to walk with support of a stick, and eat with his left hand after the episode of stroke. Gradually he stopped alcohol and smoking.

Once in a month he gets his routine blood work up done and buy his antihypertensive and ohas regularly 

Two months ago patient had complains of giddiness and went to hospital where doctor diagnosed him having ESKD and changed his diabetic medication. 

Since one month patient had complains of Fever and cough. Fever subsided after couple of days. Cough- productive with white sputum, associated with Dyspnea. 10 days ago patient had one episode of Epistaxis. Went to local hospital and got MRI Brain done. (Reports not available) . Later they had frequent checkups at various hospitals and got CT chest done. (Reports attached below). Patient was counselled about Pulmonary kochs.







 

Since two days patient had complains of left orbital swelling and unable to recognise people., got bedridden. He was bought to our hospital for further management 




On Day 1

Patient was bought to casualty in altered sensorium

On examination

Vitals:

Temp-98.9F

PR-96bpm

RR-22cpm

BP-100/70mmhg

GRBS-70mg/dl

Spo2-94%


CVS: S1S2 Heard

R/S: BAE, B/L Rhonci present

P/A: soft

CNS

GCS-E1V1M3

Tone increased in right upper and lower limbs

Absent Deep tendon reflexes 

Positive meningeal signs


Planned for MRI Brain


Day 2

MRI BRAIN showed acute infarct in superior aspect of left ventricular hemisphere and left anterior temporal lobe.

Encephalomalacic changes in left atria to capsular region- sequalae of old infarct/ old hemorrhage

Chronic infarct in left parietal lobe para sagging al region with encephalitic changes and surrounding gliosis

Atrophy of left cerebral peduncle in midbrain- wallerian degeneration 

STR hyperintenaity in intraconal compartment of left orbit. Suggest dedicated MRI orbit study to rule out post septal orbital cellulitis


Opthalmology opinion was taken in view of left periodical swelling and raised icp features. Advised tab lyser D BD for 5 days, Tab Pan 40mg for one week, eye drops lubrix 5 drops per day for one week


Pulmonology opinion was taken and advised sputum trunaat,afb,GS,FS

ATT was started according to Renal doses


On Day 3

Lumbar puncture was done. CSF gram stain showed gram negative bacilli and predominantly neutrophils were present 

MRI orbit showed

Edematous and hyperintense extraocular muscles especially medial and inferior recti muscles on left side

Stir hyper intensity of orbital fat of intraconal compartment in left side

No subperiosteal abcess formation 

No evidence of sinusitis on the ipsilateral side

Eyeballs appear normal

Mild hyper intensity of optic nerve on left side 

Evidence of preseptal tissue swelling on left side

F/S/O preseptal and postseptal orbital inflammation on left side

Right orbit and its contents are normal

Mild increase in size of acute left cerebellar infarction which is now seen extending into left lateral aspect of brain stem


ENT opinion was taken in view of nasal bleeding and ?mucormycosis

Advised to refer to higher center in view of need of multimodality approach for medical and surgical management 

Inj Liposomal Amphotericin V (5mg/kg body weight per day)

Patient was referred to higher center 

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