Anesthesia and Intensive Care Treatment

Biography

Biography: Kishor Khanal

Abstract

•      A 51 year old male from Western Nepal presented to Bharatpur College of Medical sciences with headache, vomiting and abnormal behavior in the form of irrelevant talking for 3 days. There were no episodes of seizures.  CSF examination showed total cell count of 800 with 58% eosinophils,sugar of 20.5 gm/dl and protein of 171 mg/dl. Investigations done for dengue,leptospirosis and malaria were all negative and CT scan was normal. A provisional diagnosis of  Tubercular meningitis was made and anti-tubercular therapy was started empirically. As the patient failed to improve,he was referred to Tribhuwan University Teaching Hospital. After 2 days he was intubated and shifted to ICU for sudden fall in GCS (E1M1V1). His cranial nerves were intact and the meningeal signs were absent. CSF routine examination revealed a cell count of 280 with 10% Eosinophils and no red cells. The  opening pressure was 12 cm of water. CSF wet mount preparation revealed trophozoites of Naegleria fowleri and CSF culture grew Naegleria fowleri.The CT scan findings were normal. The patient’s GCS still failed to improve and tracheostomy was done after 14 days of intubation. The wet mount preparation of CSF examined after the completion of intrathecal Amphotericin still showed motile trophozoites of Naegleria. Gradually his pupils became sluggishly reactive and ultimately pupillary reflexes along with other brainstem reflexes were absent on 19^th day of admission to ICU. One day later he went into asystole and CPR was done but he could not be revived. He was then decleared dead on 20th day of admission to ICU. 

•      Naegleria fowleri PAM is both a diagnostic and therapeutic challenge in ICU. It presents in a manner very similar to acute bacterial meningitis but, because it is much less common than pyogenic meningitis, the diagnosis may be missed initially. In the index case we presented,we diagnosed the case with the microscopy of wet mount preparation and confirmed with culture on nutrient agar.The limitation of our diagnosis was that molecular diagnostic tests could not be performed due to unavailability. We administered a combination of drugs used during the successful treatment of few survived cases at doses mentioned in the case reports. The result of our case management is different than other studies in that the duration of survival of the patient was longer than that  mentioned in most case reports with  mortality.