Pearls from 4/13/21 Medicine LEADS

Tuesday, April 13, 2021

The April 13, 2021 session of Duke Medicine LEADS featured a discussion led by Kim Darlington, MD, PhD; Vinay Choksi, MD; and Neha Kayastha, MD, "Oh, Rats! Another Case of Encephalopathy"

Panelist included, Eileen Maziarz, MDMatthew Luedke, MD, FACNS; and Xunrong Luo, MD, PhD, who weighed in for the diagnostic reasoning discussion.

In this session, we learned from a patient who had a history of kidney transplant and presented with subacute encephalopathy and was ultimately diagnosed with encephalitis secondary to lymphocytic choriomeningitis virus (LCMV). Here are pearls and takeaways:

  1. The differential diagnosis for encephalopathy is broad, especially in an immunocompromised patient. Having a strategic approach that focuses on patient and environmental characteristics and defining the clinical syndrome can help ensure a comprehensive workup.
  2. The VINDICATES mnemonic is a good approach for patients with encephalopathy, remembering that structural etiologies of encephalopathy often carry a higher risk of immediate mortality than functional etiologies. Even if neuroimaging is not impressive, lumbar punctures can be more diagnostic. Serial LPs may be helpful in elucidating a diagnosis.
  3. Immunosuppression for patients with kidney transplant usually comes in two flavors: calcineurin inhibitors and antimetabolites. When dealing with an acute infection, the right answer is generally to decrease immunosuppression, usually in a stepwise manner if the clinical scenario allows for it. A reasonable approach is to decrease / stop the antimetabolite first and then adjust the calcineurin inhibitor.
  4. LCMV is an arenavirus whose reservoir is rodents.
  5. LCMV is an extremely rare cause of encephalitis, with treatment course not well-defined. Our patient was treated with IVIG and ribavirin.

Watch the recorded session

Duke Medicine Learning, Education, and Discussion Series (LEADS) takes place each Tuesday at 12 p.m. Learn more and see schedule of upcoming sessions.