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Deep coma and diffuse white matter abnormalities caused by sepsis-associated encephalopathy

2013; Elsevier BV; Volume: 381; Issue: 9884 Linguagem: Inglês

10.1016/s0140-6736(13)60682-0

1474-547X

Merel J.A. Luitse, Charlotte J.J. van Asch, Catharina J.M. Klijn,

Intensive Care Unit Cognitive Disorders

In January, 2012, a 53-year-old woman with a history of progressive polyposis coli and hypertension was admitted to the intensive care unit (ICU) of our hospital because of septic shock 4 days after laparoscopic subtotal colectomy. She was intubated and mechanically ventilated, underwent emergent re-laparotomy for anastomotic leakage, and was treated with antibiotics. Blood cultures were positive for multiresistant Enterococcus faecium. After re-laparotomy the patient was sedated with midazolam for 2 days. The neurologist was consulted on the fourth postoperative day because of the patient's persistent low level of consciousness. On neurological examination, we found no eye opening or motor response to a painful stimulus, intact brainstem reflexes, and generalised areflexia of arms and legs with indifferent plantar reflexes. We observed no signs indicative of minimally convulsive status epilepticus. During the period of septic shock and surgery, blood pressure had not been lower than 100/50 mm Hg and laboratory tests did not show abnormalities that could explain the patient's coma. Non-contrast CT (NCCT) of the brain showed abnormal hypodensity of the complete white matter with swelling of the entire brain (figure); CT angiography was normal. Electromyography showed absence of motor unit potentials in arm and leg muscles without evidence for accompanying neuropathy. We made a diagnosis of sepsis-associated encephalopathy and critical illness myopathy. Because of the deep coma and the diffuse and severely abnormal aspect of the white matter—both associated with poor outcome—discontinuation of treatment was discussed, but we recommended to continue treatment. (A) Non-contrast CT of the brain 5 days after septic shock, showing abnormal hypodensity of the complete white matter with swelling of the entire brain. (B) MRI fluid attenuated inversion recovery imaging of the brain 4 weeks after septic shock, showing a small number of white matter lesions and no signs of infarcts.