Thread by @nirmalregency

Learning through mistakes.
(1/11) 38F. 90kg. No PMH. Fever x 3-4D ☞ body pains.
D6: frequent seizures. Multiple ASMs.
D7: CT head + CSF WNL.
D11: MR brain WNL (not shown).
D13: Repeat CSF WNL.
D16: Repeat MR Brain👇 faint b/l medial temporal hyperintensities.
Acyclovir ✅

(2/11) D19: shifted here.
Seizures ++, mostly over face w/ partial preserved consciousness.
Intubated. 4 ASMs ☞ Ketamine bolus ☞ infusion.
D19: IVIG + IV MPS also started.
Repeat CSF: routine normal. CSF BioFire -ve, including HSV. Acyclovir stopped.

(3/11) CSF autoimmune encephalitis panel -ve👇Serum paraneoplastic antibody panel -ve 👇

(4/11) Had aspirated.
BAL: BioFire: Acinetobacter+, Pseudomonas +, INFLUENZA A +👇

(5/11) D24: repeat MR 👇 B/L medial temporal hyperintensities more prominent. Symmetrical.

(6/11):
Temporal lobe encephalitis can have varied etiologies.
academic.oup.com/cid/article/60…
Continuum: doi: 10.1212/CON.0000000000001244
Point to remember: Symmetrical medial temporal hyperintensities are mostly not herpetic.

(7/11) Rx: On stopping Ketamine ☞ 48H Sz recurred. Again Ketamine x 48H + oral topiramate (TPM) loading (800mg x 24 hours) added to daily PHT 400mg, LEV 4gm, VPA 3gm, PHB 300mg.
Yes oral TPM can be used for loading in refractory SE.
onlinelibrary.wiley.com/doi/full/10.11…

(8/11) Topiramate w/ sodium valproate may have synergistic effects. frontiersin.org/articles/10.33…

9/11) But post TPM pt became dull/unarousable.
D32: urgent repeat MR👇, no additional findings.

(10/11) Serum ammonia x 2, transaminases x 10 times.
We had made a MISTAKE. TPM can precipitate VPA induced encephalopathy.
onlinelibrary.wiley.com/doi/10.1111/j.…

(11/11) Stopped VPA + TPM. Nxt 24-48 hours alert. D40: discharged walking/smiling.
Our Dx: Febrile infection-related epilepsy syndrome (FIRES) triggered by Influenza A.
We would like expert comments & suggestions. Is the Dx correct?
#Medtwitter #Neurotwitter #FIRES #Radres

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