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Area of Science:

  • Neurology
  • Toxicology
  • Internal Medicine

Background:

  • A 54-year-old male presented with decreased consciousness, respiratory failure, and rhabdomyolysis.
  • Initial workup revealed opiate toxicity and alcohol abuse history, with minimal response to naloxone.
  • The patient was admitted to the ICU and discharged after 8 days with neurology follow-up.

Purpose of the Study:

  • To investigate the cause of a patient's progressive encephalopathic presentation after initial recovery.
  • To differentiate between potential causes of neurological decline including intoxication, withdrawal, or other underlying conditions.

Main Methods:

  • Clinical presentation and history review.
  • Initial diagnostic workup including toxicology screens, electroencephalography (EEG), and unenhanced head CT.
  • Subsequent diagnostic workup including repeat head CT and magnetic resonance imaging (MRI) for persistent neurological symptoms.

Main Results:

  • Initial presentation complicated by hypercapnic respiratory failure, acute renal failure, and rhabdomyolysis.
  • EEG showed moderate bilateral cerebral dysfunction and encephalopathy.
  • Despite initial recovery and discharge, the patient returned with progressive confusion, apathy, and bizarre behavior, with normal blood work and toxicology.

Conclusions:

  • The patient's delayed neurological deterioration suggested an underlying process not fully addressed by initial management.
  • Further advanced imaging (MRI) was crucial for investigating the persistent encephalopathic state.
  • This case highlights the importance of comprehensive evaluation for unexplained neurological decline, even after initial stabilization.