27928148 Visualization

A 28 Age - year Age - old Age African Personal_background American Personal_background woman Sex presented Clinical_event to the R Nonbiological_location Adams Nonbiological_location Cowley Nonbiological_location Shock Nonbiological_location Trauma Nonbiological_location Center Nonbiological_location in Baltimore, Nonbiological_location Maryland Nonbiological_location , for evaluation Diagnostic_procedure of right Detailed_description - sided Detailed_description paralysis Disease_disorder and left Detailed_description - sided Detailed_description paresthesias Sign_symptom after being found Clinical_event down Detailed_description in her home Nonbiological_location between Detailed_description her Detailed_description nightstand Detailed_description and Detailed_description her Detailed_description bed Detailed_description .
The symptoms began after eating Activity at a local Nonbiological_location restaurant Nonbiological_location chain Nonbiological_location , consuming Activity alcohol Activity , and smoking Activity one cigarette Detailed_description dipped in liquid Detailed_description phencyclidine Detailed_description ( PCP Detailed_description ).
She was asymptomatic Sign_symptom that Time night Time and went Activity to Activity bed Activity without complications Sign_symptom .
She was found Clinical_event down Detailed_description next Nonbiological_location to Nonbiological_location the Nonbiological_location bed Nonbiological_location the Time following Time morning Time unable Sign_symptom to Sign_symptom move Sign_symptom .
The patient denied any physical Disease_disorder trauma Disease_disorder other than falling Sign_symptom from the bed.
She had no History history History of History seizures, History sickle History cell History anemia, History fever, History urinary History or History bowel History incontinence, History or History pain History .
The patient had a history of viral Disease_disorder meningitis Disease_disorder without Detailed_description residual Detailed_description deficits Detailed_description eight Date years Date prior Date , gastric History bypass History surgery History , and cholecystectomy History , and she was treated Therapeutic_procedure for a presumed urinary Disease_disorder tract Disease_disorder infection Disease_disorder five Date days Date prior Date to admission at an outside Nonbiological_location institution Nonbiological_location .
Her triage vital Diagnostic_procedure signs Diagnostic_procedure were as follows: temperature Diagnostic_procedure 36.8°C Lab_value , blood Diagnostic_procedure pressure Diagnostic_procedure 155/100 Lab_value mm Lab_value Hg Lab_value , heart Diagnostic_procedure rate Diagnostic_procedure 90 Lab_value beats Lab_value per Lab_value minute Lab_value , respiratory Diagnostic_procedure rate Diagnostic_procedure 16 Lab_value breaths Lab_value per Lab_value minute Lab_value , and an oxygen Diagnostic_procedure saturation Diagnostic_procedure of 95% Lab_value on room Detailed_description air Detailed_description .
On physical Diagnostic_procedure exam Diagnostic_procedure , the patient was alert Sign_symptom and oriented Sign_symptom to person Detailed_description , place Detailed_description , and time Detailed_description .
Her cranial Diagnostic_procedure nerves Diagnostic_procedure II Diagnostic_procedure – XII Diagnostic_procedure were grossly Lab_value intact Lab_value .
She had 2/5 Lab_value strength Diagnostic_procedure in her right Biological_structure lower Biological_structure extremity Biological_structure , 3/5 Lab_value in her left Biological_structure lower Biological_structure extremity Biological_structure , and 4/5 Lab_value bilaterally Biological_structure in Biological_structure her Biological_structure upper Biological_structure extremities Biological_structure .
Her sensation Diagnostic_procedure was intact Lab_value .
She opened Lab_value her eyes Diagnostic_procedure spontaneously Detailed_description , her verbal Diagnostic_procedure response Diagnostic_procedure was oriented Lab_value and appropriate Lab_value , and she obeyed Lab_value commands Diagnostic_procedure , resulting in a Glasgow Diagnostic_procedure Coma Diagnostic_procedure Scale Diagnostic_procedure score of 15 Lab_value .
Pupils Diagnostic_procedure were equal Detailed_description , round Shape , and reactive Lab_value to Lab_value light Lab_value .
She had tenderness Sign_symptom to palpation Detailed_description over the cervical Biological_structure , thoracic Biological_structure , and lumbar Biological_structure spine Biological_structure without obvious external signs Sign_symptom of Sign_symptom trauma Sign_symptom .
Her anal Diagnostic_procedure sphincter Diagnostic_procedure tone Diagnostic_procedure was intact Lab_value .
Multiple laboratory Diagnostic_procedure abnormalities Lab_value were noted on admission, including hyperlactemia Sign_symptom , elevated Lab_value liver Diagnostic_procedure function Diagnostic_procedure tests, and electrolyte Sign_symptom derangements Sign_symptom .
Her complete Diagnostic_procedure blood Diagnostic_procedure count Diagnostic_procedure and remainder of her complete Diagnostic_procedure metabolic Diagnostic_procedure panel Diagnostic_procedure were within Lab_value normal Lab_value limits Lab_value .
These Other_entity values Other_entity are Other_entity summarized Other_entity along Other_entity with Other_entity reference Other_entity ranges Other_entity in Other_entity Table Other_entity 1 Other_entity .
Her toxicology Diagnostic_procedure screen Diagnostic_procedure was positive Lab_value for PCP Diagnostic_procedure .
Blood Diagnostic_procedure cultures Diagnostic_procedure drawn on admission grew the aerobic Detailed_description bacteria Detailed_description Salmonella Disease_disorder enterica Disease_disorder serotype Detailed_description 4,12: Detailed_description i Detailed_description , and then repeat Diagnostic_procedure cultures Diagnostic_procedure drawn two Date days Date later Date grew group Detailed_description B Detailed_description streptococcus Disease_disorder ( aerobic Detailed_description and non Detailed_description - aerobic Detailed_description ).
Subsequent blood Diagnostic_procedure cultures Diagnostic_procedure were negative Lab_value , as were stool Diagnostic_procedure cultures Diagnostic_procedure .
Metronidazole Medication and vancomycin Medication therapy was initiated empirically, with transition to ceftriaxone Medication upon learning of the culture results.
In addition, she had a detailed autoimmunity Diagnostic_procedure workup Diagnostic_procedure including anti Diagnostic_procedure - nuclear Diagnostic_procedure antibody Diagnostic_procedure ( ANA Diagnostic_procedure ) and HLA Diagnostic_procedure - B27 Diagnostic_procedure , all of which returned within Lab_value normal Lab_value limits Lab_value .
Admission computerized Diagnostic_procedure tomography Diagnostic_procedure scan of her cervical Biological_structure , thoracic Biological_structure , and lumbar Biological_structure spine Biological_structure revealed no spinal Biological_structure fractures Disease_disorder .
Magnetic Diagnostic_procedure resonance Diagnostic_procedure imaging Diagnostic_procedure ( MRI Diagnostic_procedure ) revealed no acute intracranial Biological_structure abnormalities Sign_symptom , but enhancement Diagnostic_procedure within Diagnostic_procedure the Diagnostic_procedure central Diagnostic_procedure aspect Diagnostic_procedure of Diagnostic_procedure C3 Diagnostic_procedure – T2 Diagnostic_procedure suggested spinal Biological_structure cord Biological_structure edema Sign_symptom , disc Sign_symptom protrusions Sign_symptom at C3–4, C4–5, and C5–6, and bilateral Biological_structure posterior Biological_structure neck Biological_structure muscle Biological_structure edema Sign_symptom .
A lumbar Therapeutic_procedure puncture Therapeutic_procedure was not initially performed upon patient admission due to concerns about raised intracranial pressure from suspected trauma.
Four Time hours Time after Time presentation, her strength Diagnostic_procedure had progressively deteriorated Lab_value to 1/5 Lab_value in all Biological_structure extremities Biological_structure .
She lost Lab_value proprioception Diagnostic_procedure in her toes Biological_structure bilaterally Detailed_description and developed absent Lab_value anal Diagnostic_procedure sphincter Diagnostic_procedure tone Diagnostic_procedure .
The patient was admitted Clinical_event to the neurotrauma Nonbiological_location intensive Nonbiological_location care Nonbiological_location unit Nonbiological_location with further deterioration ultimately requiring endotracheal Detailed_description intubation Therapeutic_procedure due to respiratory Disease_disorder failure Disease_disorder .
Upon her positive blood culture results, lumbar Therapeutic_procedure puncture Therapeutic_procedure was performed, which demonstrated a pattern consistent with ATM Disease_disorder , the results of which are summarized in Table 2.
An extensive workup Diagnostic_procedure for Diagnostic_procedure infectious Diagnostic_procedure etiologies Diagnostic_procedure was also completed, with the results summarized in Table 3.
Plasma Therapeutic_procedure exchange Therapeutic_procedure therapy Therapeutic_procedure was initiated with a suspected diagnosis of ATM Disease_disorder .
Despite maximal Detailed_description medical therapy Therapeutic_procedure , the patient remains quadriplegic Disease_disorder , is experiencing neurologic Biological_structure pain Sign_symptom , received a tracheostomy Therapeutic_procedure due to prolonged Detailed_description respiratory Disease_disorder failure Disease_disorder , and required a feeding jejunostomy Therapeutic_procedure tube Therapeutic_procedure placement at the time of this report.