Case 142: update 1

Many thanks for all your suggestions. We have some more information about the patient.

She is a normally fit and well and is currently pregnant (23 weeks gestation). This is her first ever pregnancy and has been, until now, uncomplicated. Her anomaly scan done at 20 weeks gestation was unremarkable – the foetus is growing normally and there were no concerns.

She was brought in earlier on in the afternoon by her partner as she has been behaving oddly and has been disorientated for the last 24 hours. Her GCS is currently 14/15 (confused speech) and she is not orientated to time or place. She is also reporting a throbbing headache and some abdominal pain. Other than some petechiae on her lower limbs, she has no bleeding symptoms.

Her observations are normal except for a heart rate of 105 bpm and a temperature of 38.1 degrees Celsius. Blood pressure is 119/70. She has some mild photophobia but no nuchal rigidity. A CT brain was done, which is reported as normal. Admission blood tests are seen below. The working diagnosis from the medical team is viral encephalitis.

While the medical SHO is relaying this history, you get another call from the haematology laboratory about an urgent blood film (see image below).

Full blood count
Hb 71              (115-165)
MCV 92           (80-100)
Platelets 13     (150-450)
WCC 7.0         (4.0-11.0)
Neut 5.2          (2.0-8.0)

Coagulation
PT 15              (11-15)
APTT 31          (25-35)
Fibrinogen 6.7 (1.5-5.0)

Biochemistry
Na 142            (133-146)
K 4.9               (3.5-5.3)
Creat 101        (45-85)
Bili 72              (0-21)
ALT 49            (0-40)
ALP 102          (30-130)
CRP 23           (0-5)



What is the differential diagnosis and how would you differentiate between the possibilities?

What are the next steps you would take, including further investigation and management?

Who else would you want to involve in the patient’s care?

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