Intoxication/Substances/Inflammation Flashcards
Ethanol Intoxication
Pathophysiology:
- nonalcoholics: blood etoh corresponds w clinical picture
- alcoholics: high etoh w/out apparent intoxication
serum mOsm actual > calculated by 22 osm per 100 mg/dL EtOH in the blood
Clinical:
- nystagmus
- dysarthria
- limb/gait ataxia
- hypoglycemia
Dx/Rx: thiamine (prevents Wernicke’s encephalopathy)
–> add thiamine before glucose?
Ethanol Withdrawal Big symptoms
- tremulousness and hallucinations
- seizures
- delirium tremens
Ethanol Withdrawal : tremulousness and hallucinations
Pathophysiology: Clinical: - agitation - anorexia - nausea - tachycardia
Dx/Rx:
- diazepam
- chlordiazepoxide
Ethanol Withdrawal : seizures
Pathophysiology: occurs within 48h of cessation of etoh
- 40% single seizure; 90% multiple seizures
Clinical:
- usually not focal
- lasts <6h
Dx/Rx:
- most resolve spontaneously
- ppx: diazepam, chlordiazepoxide
Ethanol Withdrawal : delirium tremens
Pathophysiology: 3-5 days s/p etoh cessation
lasts <72h
Clinical:
- confusion
- agitation
- fever
- sweating
- tachycardia
- hypertension
- hallucination
Dx/Rx:
- IV diazepam
- beta blockers
- death may result from cardiovascular collapse, infection, pancreatitis
Sedative intoxication
Pathophysiology: complications: aspiration pneumonia, CV collapse
Clinical:
- confusion/coma
- respiratory depression
- hypotension
- hypothermia
- reactive pupils
- nystagmus
- ataxia
- dysarthria
- hyporeflexia
Dx/Rx: supportive care
Sedative withdrawal
Pathophysiology: usually occursin patients taking large doses for several weeks
- symtpoms develop 1-3 d s/p cessation
Clinical:
- similar to etoh withdrawal (agitation, anorexia, nausea, tacycardia, seizures, confusion…hallucination? fever? sweating? htn?)
- myoclonus, seizures
Dx/Rx: confirm dx with pentobarbital admin (no rxn confirms dx)
treat: phenobarbital taper
Opioid intoxication
Pathophysiology: confirm dx with naloxone admin Clinical: - respiratory depression - pinpoint pupils (constricts in bright light) - coma - pulmonary edema - urinary retention - decreased GI motility Dx/Rx: IV naloxone, ventilatory support
Anticholinergic intoxication
Pathophysiology: - "blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, bowel and bladder lose their tone, heart runs alone" Clinical: - dilated pupils, blurry vision - agitation, hallucinations - flushing - fever - dry skin, mucous membranes - urinary retention, constipation - tachycardia
Dx/Rx: physostigmine (cholinesterase inhibitor)
Phenylcyclidine
Pathophysiology: Symptoms resolve within 24h Clinical: -drowsiness -agitation -disorientation -amnesia? - hallucinations - paranoia - nystagmus - ataxia - hypertonicity - hyperreflexia - myoclonus Dx/Rx: - benzodiazepenes for muscle spasm - antihypertensives -anticonvulsants -dantrolene
Hypothyroidism (Myxedema)
Pathophysiology: decreased T3, T4; increased TSH Clinical: - delayed relaxation of DTRs -flat affect, psychomotor retardation -agitation, psychosis -dysarthria, ataxia -hypoglycemia -hyponatremia -LP: increased CSF protein Dx/Rx: Levothyroxine +/- hydrocortisone
Hyperthyroidism (Thyrotoxicosis)
Pathophysiology: increased T3, T4 Clinical: Younger patients: agitation, hallucinations, psychosis Older patients (>50): apathy, depression all: - hyperreflexia -physiologic tremor Dx/Rx: - propylthiouracil or methimazole - iodine - propanolol -hydrocortisone
Hypoglycemia
Pathophysiology: most commonly seen 2/2 insulin administration in diabetic patients - also seen in etoh, malnutrition, hepatic failure, insulinoma Clinical: - tachycardia -sweating -pupillary dilation - +/- seizures, loss of consciousness Dx/Rx: D5W
Hyperglycemia
Pathophysiology: DKA vs. Hyperosmolar hyperglycemic DKA: young, DM1, glucose 300-600, osm350, no ketosis, no metabolic acidosis, +coma, +seizure Clinical: - blurred vision - dry skin - anorexia - polyuria, polydipsia DKA: kussmaul respiration hyperosmolar hyperglycemic: hypotension, dehydration, focal neuro signs, seizures Dx/Rx: - insulin - fluids - correct K+, phos - allow glucose to remain at 200-300 for 24h to prevent cerebral edema
Hypoadrenalism
Pathophysiology: decreased cortisol Clinical: - fatigue -weight loss -anorexia -hyperpigmentation (increased acth) -hypotension -n/v/d -confusion vs. seizure vs. coma Dx/Rx: - hydrocortisone -correct hypoglycemia, hyponatremia
Hyperadrenalism
Pathophysiology: - usually results from administration of exogenous corticosteroids -confirm dx w 24h urine cortisol or dexamethasone suppression test Clinical: -truncal obesity -flushing -hirsutism -menstrual irregularities -cutaneous striae -acne -depression vs. euphoria - +/- psychosis, memory impairment
Dx/Rx:
Hyponatremia
Pathophysiology: acute brain swelling can result from hypoosmolarity of extracellular fluid
- neurologic complications a/w serum Na<120
Clinical:
- headache, n/v
- lethargy
-weakness
-confusion
-muscle cramps
-papilledema, tremor, asterixis, seizures
Dx/Rx: correct hyponatremia slowly (to avoid central pontine myelinolysis)
Hypercalcemia
Pathophysiology: neurologic sx present when Ca2+ >17 mg/dL Clinical: - thirst - polyuria - constipation -n/v, abd pain -nephrolithiasis - h/a, lethargy, weakness Dx/Rx: IV hydration, occult cancer evaluation
Hypocalcemia
Pathophysiology: symptoms at serum Ca levels s sign: carpopedal spasm s/p tourniquette
Dx/Rx: calcium gluconate, IV phenytoin if seizures
Wernicke’s encephalopathy
Pathophysiology:
-usually a complication of etoh 2/2 thiamine deficiency
-neuronal loss, demyelination, gliosis
- macrocytic anemia
Clinical:
- ophthalmoplegia
-ataxia
-confusional state: prominent d/o of immediate recall and memory
- long term complications: Korsakoff syndrome: anterograde + retrograde amnesia, confabulation, lack of insight, apathy
Dx/Rx: thiamine!
Vitamin B12 deficiency
Pathophysiology:
- usually 2/2 pernicious anemia (autoimmune response to intrinsic factor)
- neuro symptoms may precede macrocytic anemia
- hypersegmented neutrophils
Clinical:
- peripheral neuropathy
- nutritional vision loss (centrocecal scotoma)
- gait ataxia
- Lhermitte sign: electric shock-like sensation down spine with neck flexion
- low grade fever
- glossitis
- confusion +/- psychosis
Dx/Rx:
- methylmalonic/homovanillic acid in urine
- IV b12
- abnormalities present >1 year unlikely to resolve
Hepatic encephalopathy
Pathophysiology: -occurs as complication of cirrhosis, hepatitis, etc. (etoh most common) -liver dz produces symptoms by impairing metabolism of toxins (increased ammonia, toxin; increased GABA activity) - increased bilirubin, ast/alt, ammonia, pt, ptt Clinical: -asterixis -increased glutamate in csf -somnolence -agitation -nausea, anorexia, weight loss - nystagmus, dysconjugate gaze -Type II Alzheimer's astrocytes -fetor hepaticus (breath)
Dx/Rx:
- diatary protein restriction (this has changed)
- correct coagulopathy
- lactulose to decrease ammonia absorption
Reye syndrome
Pathophysiology: usually occurs in kids s/p viral illness - risk factor: salicylate administration Clinical: - encephalopathy +/- coma - evidence of hepatic dysfunction Dx/Rx:
Uremia
Pathophysiology: renal failure, esp when acute or rapidly progressive - increased serum urea nitrogen (BUN), creatinine, potassium -metabolic acidosis Clinical: -encephalopathy +/- coma - hyperventilation -motor manifestations -peripheral neuropathy Dx/Rx: -hydration -protein restriction -dialysis
Bacterial meningitis
Pathophysiology: bacteria gain access to CNS via colonizing the nasopharynx –> local tissue invasion –> bacteremia –> hematogenous seeding of subarachnoid space
age-stratified etiology
50 y: S.pneumoniae
Clinical:
- fever
- confusion
- vomiting
- h/a
- neck stiffness
- petechial rash seen in 50-60% w/ N.meningitidis
- Brudinski sign: flexion of knee with passive flexion of neck
- CT/MRI: contrast enhancement of cerebral convexities
- LP: increased opening pressure, PMNs, protein
Dx/Rx: antibiotics, dexamethasone
TB Meningitis
Pathophysiology: reactivation of latent TB that ruptures into the subarachnoid space
Clinical:
- fever
- lethargy
- ha
- vom
- stiff neck
- diplopia
- LP: leukocytosis w/ monos, glucose <20, + AFB stain
Dx/Rx: rifampin, isoniazid, pyrazinamide, ethambutol
Toxoplasmosis
Pathophysiology: toxoplasma gondii from undercooked meat vs. cat excrement - symptomatic infection a/w Hodgkin's dz, immunosuppression, AIDS Clinical: - usually asymptomatic -skin rash -lymphadenopathy -myalgia -CT: ring enhancing lesions
Dx/Rx: pyrimethamine + sulfadiazine
Cystercercosis
Pathophysiology: follows ingestion of pork tapeworm taenia solium
- symptoms result from mass effect of intraparenchymal cysts
Clinical:
- peripheral, CSF eosinophilia
- h/a
- hydrocephalus
- myelopathy
Dx/Rx: albendazole
Metastases
Pathophysiology: diffuse metastatic seeding may complicate systemic cancer, esp: - acute lymphocytic leukemia (ALL) - NHL (non-Hodgkin's lymphoma) - melanoma - breast carcinoma - occurs 3 mos-5 years after dx
Clinical:
- h/a
- lethargy
- confusion +/- memory impairment
- LP: VERY low glucose, + malignant cells, + HCG, AFP, CEA
Dx/Rx: radiation, chemotherapy
HTN Encephalopathy
Pathophysiology: sudden increase in bp +/- chronic HTN
- bp >250/250 to see symptoms
- increased risk in renal failure
- due to cerebrovascular spasm, impaired autoregulation, intravascular coagulation, etc.
Clinical:
- -> retinal arteriolar spasm: papilledema, retinal hemorrhage, exudates
- vomiting
- focal neurologic deficits
- +/- seizures
Dx/Rx: IV sodium nitroprusside
Lyme disease
Pathophysiology: borrellia burgdorferi
Clinical:
- erythema migrans upon acute infection
- meningitis or meningoencephalitis 5-10 wks s/p exposure
- +/- cardiac conduction abnormalities
Dx/Rx:
- doxycycline x 4wks
- ceftriaxone IV x 4 wks if meningitis
HSV Encephalitis
Pathophysiology:
- usually >40 yo
- HSV1 latent reactivation w/ spread along cranial nerves
- acute, hemorrhagic, necrotizing process in medial temporal lobe
Clinical:
- h/a, n/v
- stiff neck
- behavioral changes
- anosmia
- hemiparesis
- LP: increased RBCs in CSF
Dx/Rx: acyclovir (early!)
SLE
Pathophysiology:
- most common autoimmune encephalopathy
- F>M (9x) w/ o/s 10-40y
- usually correlates w vasculitis, mucositis
Clinical:
- seizures
- altered mental status
- (+) ANA, dsDNA antibodies
Dx/Rx:
- corticosteroids
- +/- anticonvulsants
DIC
Pathophysiology:
- pathologic activation of coag + fibrinolytic system in setting of systemic illness
- small multifocal infarcts w/ petechia hemorrhage in white and gray matter
Clinical:
- coma
- focal neuro deficits
- seizures
Dx/Rx:
- transfusion
- fresh frozen plasma (all coagulation factors)
TTP
Pathophysiology:
- thought to be IgG mediated reaction against vWF –> large vWF aggregates stimulate platelet aggregation
- can be precipitated by antiplatelet agents
- normal PT/PTT
Clinical:
- thrombocytopenic purpura
- microangiopathic hemolytic anemia
- neurologic dysfunction
- fever
- renal disease
- h/a, altered mental status
- hemolytic anemia
- schistocytes
Dx/Rx: plasmaphoresis
Alzheimer’s disease
Pathophysiology:
- increased risk in trisomy 21, mutations in amyloid precursor protein, increased APOE4 alleles on chromosome 19
- beta-amyloid is constituent of neuritic plaques
- decreased cholinergic neurons in cerebral cortex, hippocampus
Clinical:
- impairment in recent memory
- disorientation in time, space
- aphasia, anomia, acalculia
- psychosis, hallucinations
- death 5-10 yrs s/p onset
Dx/Rx:
- memantidine (NMDA=glutamate receptor antagonists)
- acetylcholinesterase inhibitors
Creutzfeldt-Jakob
Pathophysiology:
- invariably fatal, transmissible
- infectious agent =prion accumulation
Clinical:
- rapidly progressive dementia
- myoclonus
- extrapyramidal symptoms
Dx/Rx:
Normal Pressure Hydrocephalus
Pathophysiology: communication hydrocephalus 2/2 decreased absorption of CSF
Clinical:
- dementia
- gait apraxia (initial manifestation)
- incontinence
Dx/Rx:
- LP
- shunting (VP)
Diffuse Lewy Body Disease
Pathophysiology:
- 2nd most common dementia
- Lewy bodies contain alpha-synuclein, tau
Clinical:
- cognitive decline without prominent motor symptoms
1) cognitive fluctuations
2) auditory or visual hallucinations
3) Parkinsonism (rigidity, akinesia)
Dx/Rx:
- anticholinesterase
- caution with neuroleptics (antipsychotics)
Neurosyphilis
Pathophysiology:
- treponemal tests (FTA-ABS) are reactive in active neurosyphilis
- non-treponemal tests (VDRL, RPR) can be negative
Clinical:
General paresis:
- meningoencephalitis 2/2 active spirochetal infection
- gradual change in memory, personality, behavior
Tabes Dorsalis:
- Argyll Robertson Pupil (accommodates but does not react to light)
- lancinating pains
- areflexia
- optic atrophy
- hypertrophic joints
- hyperextended knees
Dx/Rx:
- penicillin G (IV or IM)
- Jared-Herxheimer reaction: fever, leukocytosis occurring shortly after therapy begins (reaction to endotoxins released due to death of harmful organisms)
Progressive Multifocal Leukoencephalopathy
Pathophysiology:
- results from JC virus infection
- common in AIDS, lymphoma, leukemia, carcinoma, TB, sarcoid, immunosuppression
Clinical:
- dementia
- focal neurologic deficits
Dx/Rx: watch for IRIS (immune reconstitution inflammatory syndrome)
Vascular dementia
Pathophysiology:
- 3rd most common cause of dementia
- most patients have significant past infarcts
Clinical:
- abrupt onset of dementia with focal signs and symptoms
- pseudobulbar palsy: dysarthria, dysphagia, pathologic emotionality
Dx/Rx: treat htn
