Confusion in a patient with mycoplasma pneumonia lowers threshhold to lumbar puncture despite hyponatremia.

A 55 year old Indonesian male known case of DM on oral hypoglycaemic drugs presented to ER with productive cough for 3 days. He had no history of SOB, neither haemoptysis, vomiting, haematuria nor bleeding. On physical examination, he appeared disoriented agitated, pale, jaundiced and with good body built. He was not distressed without any cyanosis, clubbing or sign of dehydration. His temperature was 39.3˚C. Laboratory investigation revealed WBC count of 22 /ml, HB 7, 5 gm/dl normochromic normocytic anaemia, normal platelet and normal AB, random blood sugar 320 ml/dl, urea 140 ml/dl, creatinine 2.5 ml/dl , LDL 1500, total bilirubin 3 mainly indirect. CT brain was clear. CSF analysis showed 10 cells 100% lymphocytes, protein 100mg/dl (high) and glucose 160 mg/dl (normal). The patient was initially treated with I.V hypertonic saline, ceftriaxone, vancomycin, acyclovir and dexamethasone, insulin and diet management. Two days later. patient showed improvement in his level of conscious as his Na become 121 mg/dl, urine output 600ml/day, but patient still had high grade fever on-going haemolysis, erythromycin was started and an obvious improvement happened, he become communicating, afebrile, LDH decrease from 2000 to 750, with increase HB level from 6,5 g/dl to 9 g/dl. Conclusively, Aseptic meningitis should be considered in patient with mycoplasma pneumonia presented with confusion despite he has hypernatremia.

Pellagra in association with hallucination and over-salivation.

A 33 yr old African female, living in Makkah, presented to ER with decreased LOC & diarrhoea which was observed by the attending nurse with no more available history .On examination: she was afebrile; Pulse rate was 100 bpm, BP 90/60 mmHg, R/R 18 breaths/min, O2 sat. 98% on room air. She was disoriented having hallucination, underweight, dehydrated, pale. She was diagnosed as acute confusional state, and she received IVF, PRBC, and correction of electrolytes. Patient has received empirical antibiotics since admission and for 3 days, and conservative treatment but has not improved yet! On the 4th day of admission, niacin deficiency was suspected. Therefore, niacin was started at dose of 100 mg BID per oral. By the 6th day of the hospital stay, patient had become oriented, communicating, with no diarrhoea, and the skin lesion started to improve. In conclusion, this case calls attention to pellagra when considering the differential diagnosis of hallucination and oversalivation