Model Answer
0 min readIntroduction
High-grade fever accompanied by altered mental status, such as stupor, in a young adult is a medical emergency demanding prompt diagnosis and intervention. The differential diagnosis is broad, encompassing infectious diseases like meningitis, encephalitis, sepsis, and systemic infections with neurological involvement, as well as non-infectious causes like drug intoxication, metabolic disturbances, and structural brain lesions. Cerebral malaria, a severe complication of Plasmodium falciparum infection, is a significant cause of morbidity and mortality, particularly in endemic regions. Early recognition and appropriate management are crucial for improving patient outcomes.
(i) Causes of Stupor with High-Grade Fever in an 18-year-old
An 18-year-old presenting with stupor and high-grade fever necessitates a comprehensive evaluation. The causes can be broadly categorized as infectious and non-infectious.
- Infectious Causes:
- Meningitis: Bacterial, viral, or fungal meningitis can cause rapid deterioration of mental status.
- Encephalitis: Viral encephalitis (e.g., Japanese encephalitis, Herpes simplex encephalitis) often presents with fever and altered consciousness.
- Cerebral Malaria: A life-threatening complication of Plasmodium falciparum infection, characterized by impaired consciousness, seizures, and other neurological manifestations.
- Sepsis: Systemic inflammatory response to infection, leading to organ dysfunction, including neurological compromise.
- Typhoid Fever: Severe cases can lead to altered mental status.
- Dengue Fever: Dengue hemorrhagic fever and dengue shock syndrome can present with neurological symptoms.
- Non-Infectious Causes:
- Drug Intoxication/Withdrawal: Exposure to toxins or withdrawal from substances can induce altered mental status.
- Metabolic Disturbances: Severe hypoglycemia, hyperglycemia, electrolyte imbalances (sodium, calcium), and hepatic encephalopathy.
- Heatstroke: Prolonged exposure to high temperatures can cause hyperthermia and neurological dysfunction.
- Structural Brain Lesions: Subdural hematoma, intracranial hemorrhage, or brain tumor (less likely with acute onset).
(ii) Management of Cerebral Malaria
Cerebral malaria requires immediate and aggressive management. The following steps are crucial:
1. Diagnosis
Diagnosis relies on clinical suspicion, peripheral blood smear for Plasmodium falciparum, and rapid diagnostic tests (RDTs). Lumbar puncture should be considered to rule out other causes of altered mental status, but is generally deferred if there are signs of increased intracranial pressure.
2. Initial Stabilization
- Airway, Breathing, Circulation (ABC): Ensure patent airway, adequate ventilation, and circulatory support.
- Monitoring: Continuous monitoring of vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation), neurological status (Glasgow Coma Scale - GCS), and urine output.
- Fluid Resuscitation: Administer intravenous fluids cautiously to maintain adequate hydration, avoiding fluid overload.
- Correction of Electrolyte Imbalances: Address any electrolyte disturbances.
3. Specific Treatment
- Antimalarial Therapy:
- Artesunate: The preferred first-line treatment for severe malaria, including cerebral malaria. Administered intravenously.
- Alternatives: If artesunate is unavailable, quinine can be used intravenously, but it is less effective and has more side effects.
- Management of Complications:
- Seizures: Administer benzodiazepines (e.g., diazepam, lorazepam) to control seizures.
- Increased Intracranial Pressure (ICP): Elevate the head of the bed, consider mannitol or hypertonic saline cautiously.
- Acute Respiratory Distress Syndrome (ARDS): Provide mechanical ventilation.
- Anemia: Transfuse packed red blood cells if hemoglobin levels are critically low.
- Hypoglycemia: Administer intravenous dextrose.
4. Monitoring and Follow-up
Close monitoring of neurological status, parasite clearance, and hematological parameters is essential. Repeat blood smears should be performed regularly to assess treatment response. Long-term neurological sequelae are common, requiring rehabilitation and follow-up care.
Conclusion
The presentation of an 18-year-old with stupor and high-grade fever demands a rapid and systematic approach to identify the underlying cause. Cerebral malaria, a potentially fatal complication of <em>Plasmodium falciparum</em> infection, requires prompt diagnosis and treatment with artesunate, alongside supportive care to manage complications. A thorough differential diagnosis and consideration of both infectious and non-infectious etiologies are crucial for optimal patient management and minimizing long-term morbidity.
Answer Length
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