FEMALE WITH ACUTE

SLURRING OF SPEECH
Dr. Thisara Perera
Medical registrar Wd 16/17
28/01/2015

Introduction

Mrs. M
58 years
Vice principal
Diabetes melitus
Hypertension
10
years

History

Sudden onset of slurring of speech

Followed by drowsiness
Vomited few times
No limb weakness
No complete loss of consciousness
No abnormal movements
No definite history of fever
History of mild headache , arthralgia,
myalgia for 2 days

Patient has taken her normal meals and

routine medication
No history of loss of appetite or other
constitutional symptoms
No history of chronic headache and early
morning vomiting
No preceding history of chest pain,
palpitations or dyspnoea

Had normal bowel movements.

No history of ayurvedic medication
No alteration of sleep pattern
Normal urine output
No history of skin rash or alopecia
No preceding behavioural abnormalities

Past history

Patient was on metformin 500 mg b.i.d

for diabetes. No micro or macrovascular
complications.
On losartan 50 mg b.i.d for hypertension
Blood pressure was not well controlled
No significant surgical interventions

Examination
At ETU
GCS 14/15 (E- 3, V- 5, M- 6)
B/L PERTL
No pallor
Afebrile
Not dyspneoic
Moved all 4 limbs
No skin rashes

CNS

B/L fundi no papilloedema

No neck stiffness
No opthalmoplegia
No objective weakness
Normal reflexes and tone
Plantars B/L down
Dysarthria , but no other cerebellar signs

CVS

BP- 120/60
PR- 60 /min
DR/ no murmurs

RS

Not tachypnoeic
Lungs clear

GI

Abdomen soft, non-tender

No hepatosplenomegaly

But.
3 hours after the ETU admission
Patients GCS deteriorated 10/15
All other parameters were normal
Re- examination also similar to previous
findings

Summary

58 year old female diagnosed with

diabetes and hypertension for 10 years
presented with acute onset slurring of
speech and vomiting with no other focal
neurological signs or neck stiffness. She
had no history of fever but had 2 days of
mild headache. Following admission GCS
deteriorated from 14/15 to 10/15 within 3
hours. Other systems examination was
normal including normal blood pressure.

Problem list

Acute slurring of speech and

deterioration of consciousness
Background history 2 days of mild
headache
Past history of diabetes mellitus and
hypertension

Differential diagnoses

Cerebro-vascular event- arterial or

venous / infarction or haemorrhage
Meningoencephalitis (Bacterial/ Viral)
Metabolic encephalopathy
hypoglycaemia
Drug overdose/ snake bite

FBC

WBC- 5.8 X 109

(L- 42.6%, N- 49.9%)
Hb- 13 .1 g/dl
MCV-92 fL
MCH- 30.8 pg
Plt 146 X 109

Blood picture

Normochromic normocytic red cells

Reactive lymphocytes
Mild thrombocytopenia
Blood picture- viral infection

Inflammatory markers

CRP 0.1 mg/l

ESR 30 mm/1st hour

ABG

PH 7.41
Pco2-37 mmHg
Po2 - 100 mmHg
Na+ -133 mmol/l
K+ - 3.6 mmol/l
Glucose 164 mg/dl
Hco3 23.5

NCCT - brain

No haemorrhages or obvious infarctions

MRI

Multiple lacunar infarctions

EEG

CSF analysis

Colour- clear
Protein 23.5 mg/dl
WBC neutrophils 0
Lymphocytes 0
RBC 8
CSF sugar 82 mg/dl
RBS 140 mg/dl

LFT

SGPT- 19 u/l
SGOT- 15 u/l
ALP -146 u/l
S. protein- 6.9 g/dl
Alb 4.82 g/dl
Glob 2.08 g/dl
S. Bilirubin 1.14 mg/dl

RFT /SE

S. Na+ -141 mmol/L

S. K+ - 3.6 mmol/L
S.Creat 0.7 mg/dl
S. Urea 19 mg/dl

UFR

Pus cells 1-3 /hpf

Red cells- 45-50/hpf
Protein nil
Ketones - nil

Patient was given a provisional diagnosis

of meningitis/ encephalitis and IV
acyclovir and IV ceftriaxone started.

Day 2 of admission patients

consciousness improved
Day 3 GCS 15/15 . Orals started.
Patient well oriented.

Day 4

Patient became confused and

disoriented.
GCS deteriorated down to 13/15
First fever spike recorded on the same
day.
may
be the cause/s ?
Urine What
out put
reduced
1.Is it the same diagnosis
worsening
2.Is it a complication?
3.Is it something else

An important clue ?

What is the next step?

Clotting profile

PT/ INR- 1.1

APTT -36 sec (ctrl- 34 sec )

FBC

HB- 13 g/dl
MCV- 91 fL
MCH- 31.2 pg
WBC- 8500 (N- 80% , L- 13%)
Platelets- 109 X 10 9

Renal functions

S. Creatine 480 umol/L

S. Na+ - 138 mmol/l
S.K+ - 4.0 mmol/l

Mg- 1.8 mg/dl ( 1.7-2.7)

Ca 8.1 mg/dl (8.1-10.4)

CRP- 41.6 mg/l

ALT- 29
AST- 34
ALP- 127
T. protein- 62g/l
Alb- 41 g/l
Glob- 21 g/l
T. bilirubin- 12.8 umol/l

Repeat MRI - Brain

Repeat EEG

Repeat blood picture

Red cells are normochromic normocytic

with fragmented red cells.
Neutrophil leucocytosis with mild left
shift
Platelets are moderately low
Impression - MAHA

LDH

LDH- 420 u/l (81- 234)

Thrombotic Thrombocytopenic Purpura

Deficiency of ADAMTS13 (VWF cleaving

protein)
Ultra large multimers of VWF released
and cause platelet aggregation
Microthrombi inside vessels
Untreated mortality 90%

TTP Pentad
1.
2.
3.
4.
5.

Thrombocytopenia,
MAHA
Fluctuating neurological signs
Fever
Renal impairment
35% can present without fever and
abnormal renal functions

Acute renal failure needing dialysis rare in

TTP as in HUS

Median platelet count at presentation 10

-30 X 103

The combination of haemolysis and tissue

ischaemia produces elevated lactate
dehydrogenase (LDH) values.

ADAMTS13 assay not available in Sri

Lanka

Clotting profile normal with negative

Coombs test

Troponin elevated in 50%

Aetiology Congenital and acquired

1. congenital
2. acute idiopathic- most common.
3. autoimmune- Part of SLE
4. HIV may be the presentation
5. Pregnancy
6. drugs quinine, ticlopidine, (clopidogrel doubt),
simvastatin, anecdotal reports of OCP
7. Malignancy ADAMTS not low in these patients
8 . Acute pancreatitis

Treatment

Daily plasma exchange (PE)

Mortality reduced from 90% to 10%
Large infusions of plasma if PE delayed
Daily exchanges continued after full
remission for 2 days (PLT >150)

Platelets contraindicated if not for a

life threatening haemorrhage
Immediately after PE IV
Methylprednisilone 1 g for 3 days
should be given
Oral Folic acid 5 mg daily
When platelet count >50,000 - LMW
heparin and aspirin

Malignancy associated TTP PE has poor

response. Underlying malignany should be
treated.
Rituximab has a place where PE fails and in
relapses. (Even as first line in a phase 2
trial)
Supportive therapy
Prior to discharge all patients should be
counseled regarding the risk and the
symptoms and signs of relapse

Can acyclovir cause TTP?

Sequel of the story

Hb

13

9.2

10.8

9.0

9.9

10.2

WBC

8500

8400

13000

11000

8600

7200

platelet
s

108

122

128

117

160

232

S. Creat
(umol/l)

343

480

257

139

87

78

LDH
(230460U/L)

650

705

920

739

610

513

Patient was given 8 cycles of

plasma exchange

Patient developed R/S Lower limb

swelling after the 7th cycle of plasma
exchange.

R /LL duplex- DVT involving right

external iliac and femoral vein.

No direct association between DVT and

TTP.

Take home message

TTP incidence on the rise. If a patient

presents with acute confusion dont
forget the blood picture. Have high
degree of suspicion.

Even a trivial physical finding saves life.

Acknowledgement

Dr. R.R. Weerakoon (consultant Physician)

Dr. J.D.V.C. Lekamwasam (consultant
Physician)
Dr. Malani Mohotti (consultant Haematologist)
Dr. Theshanthi Welivitiya (consultant in
Transfusion Medicine)
Dr. M.T.M Ashfaq (SR)
Staff of Wd 35.
Co- registrars