Changing Clinical Profile and Predictors of Mortality in Patients of Acute Febrile Encephalopathy from North India

Introduction

Acute encephalitis syndrome (AES) or acute febrile encephalopathy is a clinical condition characterized by altered mental status occurring after or along with a short febrile illness. In developing countries, infections are the predominant cause of AES. Prominent infections known to cause AES include viruses (such as herpes simplex virus [HSV], Japanese Encephalitis [JE] virus, dengue, enteroviruses [EVs]), bacteria, fungus, and parasites. In the present study, we aim to analyze the etiology, clinical features, and predictors of mortality in patients presenting with acute febrile encephalopathy or acute encephalitic syndrome. The present study was a prospective observational study conducted at Post Graduate Institute of Medical Education and Research a tertiary care center in Chandigarh, India.

Methods

A total of 105 patients with ≥18 years of age with fever (body temperature >101° F for duration ≤14 days) and altered sensorium (Glasgow coma scale [GCS] score ≤10) lasting for more than 24 h, either accompanying the fever or following it were enrolled. Demographic and clinical details were recorded on pro forma. Cerebrospinal fluid (CSF) analysis was performed for all the enrolled patients at admission for cytology, CSF glucose to blood glucose ratio, protein levels, gram stain and culture sensitivity, adenosine deaminase levels, polymerase chain reaction for HSV/EV/mycobacterium tuberculosis (TB) and immunoglobulin M Enzyme-linked immune assay for JE. Computed tomography of the brain was done in all patients while magnetic resonance imaging (MRI) of the brain was carried out in 75 patients.

Results

Among the 105 patients, tubercular meningitis was seen in 27 (25.7%) patients followed by acute pyogenic meningitis in 18 (17.1%) patients. Probable viral encephalitis was present in 12 (11.4%) cases. Septic encephalopathy (n = 10) and scrub typhus encephalitis (n = 8), HSV encephalitis (n = 6), dengue encephalitis (n = 4), leptospirosis (n = 3) were the other infections causing acute febrile encephalitis in our study. In addition to fever and altered sensorium common symptoms observed were headache (52.4%), vomiting (35.2%), and seizures (29.5%). The factors predicting increased mortality were female gender, fever of more than 38°C at admission, GCS <7, MRI showing disease-related findings like altered signal intensity bilateral medial temporal and insular area in herpes simplex encephalitis, etc., changes, and the group of patients where a definite diagnosis could not be established during the hospital stay.

Conclusions

Tubercular meningitis/central nervous system TB is the predominant cause of acute febrile encephalopathy in developing countries. Scrub and dengue encephalitis are emerging as an important cause of acute febrile encephalopathy and occur predominantly in postmonsoon seasons. Acute febrile encephalopathy remains an important cause of mortality in patients presenting to Emergency Department (ER). The strongest predictors of mortality are low GCS and undiagnosed cases of AES.

Rotablation in complex ACS versus Non-ACS patients: Prospective follow up study from tertiary care centre in North India

The purpose of this study is to compare short term outcome of rotablation in ACS versus non-ACS patients. 60 Consecutive patients who underwent rotational atherectomy were followed prospectively. The mean duration of follow up was 13.05 ± 5.2 months. The mean ejection fraction was 52.41% ± 9.4%. 45% patients had diagnosis of CSA and 55% were ACS. The mean syntax score was 29.23 ± 7.99. LAD was the most common vessel treated by RA in 76.6%. Rotablation of LM was done in 30%. IVUS guided procedure was done in 66.7%. RA can be done with comparable safety and success in both non-ACS and ACS patients.

Retrieval and repositioning of an embolized atrial septal defect closure device using a gooseneck snare

BACKGROUND

Closure of all haemodynamically significant atrial septal defects (ASDs) is recommended irrespective of symptoms. Percutaneous device closure offers a favourable alternative to surgery with lower morbidity, shorter duration of hospital stays, and avoidance of a surgical scar. Though device closure is generally a safe procedure with high success rates, certain complications can arise including device embolization which poses a significant challenge for the treating team. We report one such case in which the ASD closure device got spontaneously released and embolized from the delivery cable into the left atrium prior to its deployment. We describe our approach for its retrieval and subsequently its successful deployment across the septal defect using a gooseneck snare.

CASE PRESENTATION

A 5-year-old asymptomatic child was found to have a murmur on a routine check-up. Evaluation revealed a haemodynamically significant, 18-mm ostium secundum ASD with normal pulmonary pressures and suitable margins for device closure. A 20-mm ASD closure device was traversed via an 8-Fr delivery system. While manipulating the left atrial (LA) disc from the right upper pulmonary vein (RUPV) approach, the device got spontaneously released. The right atrial (RA) disc was caught across the ASD, into the left atrium. This was confirmed by intraoperative transthoracic echocardiography and fluoroscopy. The haemodynamics and rhythm were stable. A 20-mm gooseneck snare was immediately passed through the delivery sheath and an attempt was made to catch the screw. With difficulty, the RA screw was caught with the snare and multiple attempts to retrieve the device into the sheath were unsuccessful. However, while negotiating, we were able to secure a favourable position of the device across the atrial septal defect, and after fluoroscopic and echocardiographic confirmation, the device was released. The child remained stable thereafter and was discharged 2 days later.

CONCLUSIONS

Gooseneck snare is a valuable tool in the management of embolized ASD closure device. Occasionally, like in the index case, one may be successful in retrieving the embolized device and repositioning it across the ASD using a gooseneck snare, thus obviating the need for emergency surgery.