3. Travel and Infectious History

  • Ten days before admission, the patient returned from 2 months of
    travel in Asia
  • He prepared his own food, used only boiled water, and did not swim
    in any river or lake
  • He was in his usual state of good health on return to the US
  • He received Japanese encephalitis vaccine prior to the trip
  • Outdoor cats at home, no scratches on patient
  • No tick or mosquito bites and no sick contacts reported
  • Japanese encephalitis usually demonstrates bilateral thalamic lesions,
    especially hemorrhage on MRI
    (Kumar S et al. Neuroradiology 39:180, 1997)

Physical Exam

  • afebrile, vital signs stable
  • lethargic, but oriented to time and place
  • no rash
  • no facial asymmetry or focal neurologic deficits
  • increased tone in the left leg but 5/5 strength in all extremities
  • Babinski reflex downgoing, no Brudzinski’s sign
  • no lymphadenopathy

Admission Labs

 Na+134(135-145 mmol/L)
 K+3.8(3.5-4.5 mmol/L)
 Cl-98(96-106 mmol/L)
 C0226(22-30 mmol/L)
 BUN11(8-18 mg/dL)
 Cr1(0.5-1.2 mg/dL)
 Ca ++8.8(8.8-10.2 mg/dL)
 Mg + +3(1.8-3.0 mg/dL)
 PO4-2.2(3.1-4.5 mg/dL)
 Phenytoin9(10-20 mg/mL)
 Hb15(14-18 g/dL)

Breakpoint #3

  • How would you proceed at this point?