Brief Answer:
Speak to neurologist

Detailed Answer:
Good evening. I am a neurologist in XXXXXXX OH. I'm very sorry that your daughter is experiencing such problems. I agree that all possibilities should be looked at in a case such as you're describing. Do you know if they did a lumbar puncture? If they did they should've cultured her for both bacterial, fungal, and viral agents. I would do a cryptococcal smear and culture in both blood and CSF. I would add an XXXXXXX Ink preparation to the CSF assay. A newer test called Lateral Flow assay on the CSF can also be done if the more expensive cryptococcal antigen test is unavailable or not covered by insurance.

I would also recommend doing a Herpes PCR assay in the cerebrospinal fluid. Also, an MRI with contrast should be performed even though the CT doesn't seem to show anything. I'd be looking for abnormalities called "petecchial hemorrhages" which are small pinpoint size areas of bleeding in the brain caused typically by a herpes infection and this is suggestive of a herpes encephalitis.

Now, having said all of the above, I would remind you that the neurologist has already seen her and done at least an EEG. Not sure why he chose not to expand the workup by getting an MR study and spinal tap...but that's for him to decide upon while seeing the patient. A little unfair for me to make a judgement call on what he did or didn't do seeing as how I haven't seen the patient.

Therefore, a conversation with him is necessary as soon as possible...especially if she's getting worse. If she had an UNTREATED fungal infection of the brain...I doubt things would remain stable and I would've expected her condition to be getting worse.

It is also reasonable in such cases where the possibility of an infectious entity such as Herpes or even a fungal agent could be present to go ahead and start appropriate medications of an antiviral or anti-fungal nature and once all that has been ruled out by testing the medications can be stopped....no real harm done.

They should also get at least several blood cultures, sputum, and urine cultures to look for other sources of infection especially if she is otherwise, asymptomatic except for the mental status changes. Also keep in mind that a single EEG is only about 30-50% for abnormal brain wave activity. In any patient with significant mental status change of unknown origin at least 2-3 EEG's should be performed in order to increase the chances of seeing an abnormality if the first is normal.

I hope this information has been useful and if I've answered your questions adequately would appreciate your written note of feedback as well as your CLOSING THE QUERY if there are no further questions that you'd like to ask of me. If you'd like to ask more questions I'm happy to directly help you now or in the future by doing a direct consultation for you at: bit.ly/drdariushsaghafi

All the very best for your daughter.

This query required 31 min. for review and response to the questions.

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Brief Answer:
Daughter having problems

Detailed Answer:
Thanks for the update.

With the tap having been performed and depending upon how much fluid was obtained as well as WHEN; the next neurologist may be able to still ask that some of that fluid be cultured and tested for the XXXXXXX Ink as well as fungal cultures and PCR analysis I mentioned. If the specimens are refrigerated they usually have a shelf life of at least a few days where other tests can be run.

Otherwise, she may need another tap. As far as being too uncooperative for an MRI- I can understand that but there are forms of sedating such individuals in a controlled and safe manner (referred to CONSCIOUS SEDATION). It may be that the hospital you're at is not optimally staffed or equipped to perform this type of sedation in the radiology dept. I can understand why they would be reticent to use oral medications if they're not sure what's causing her behavioral problems since oversedation may cause respiratory compromise independent of what or what was not done in ER.

In that instance, you may find a hospital that performs this procedure (usually an academic center will do these routinely...or just a large tertiary care facility). Alternatively, there are local community based radiology labs that can do conscious sedation if given the heads up so if it's not feasible to change hospitals you can look for such a facility to do the study. The MRI should be done with contrast and have fine cuts done through the temporal lobes looking for a condition known as MESIAL TEMPORAL SCLEROSIS.

Prolactin levels AFTER a seizure or SUSPECTED seizure/convulsion spike and then, decrease. In your daughter's case it would appear that she had high levels which are now coming down. The finding is consistent with hyperelectrical activity probably of a generalized sort of the brain as would occur in a seizure, however, it is not diagnostic.

If there's been no improvement in her mental status then, another EEG would be warranted to be read in this case by someone with experience such as a neurologist or better yet epileptologist if available.

CPK of 341 may represent just a lot of muscle activity and movement which can occur doing convulsive spells. If she hasn't had any further episodes those numbers should be coming down and are helped by simple oral or IV hydration.

I hope this information has been useful and if I've answered your questions adequately would appreciate your written note of feedback as well as your CLOSING THE QUERY if there no further questions need my attention.

If you'd like to ask more questions I'm happy to directly help you now or in the future by contacting me at: bit.ly/drdariushsaghafi

I'd love to hear if your daughter improves and what the diagnosis is in her case.

Total physician directed time of 56 min. for review and response to these questions to this point.

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