Acute Disseminated Encephalomyelitis in an Incarcerated Adolescent Presents as Acute Psychosis: Case Report and Literature Review.

OBJECTIVE: We aimed to describe a case of an incarcerated adolescent with acute disseminated encephalomyelitis (ADEM) presenting as acute psychosis. METHODS: This was a retrospective case report followed with chart and literature review. MAIN FINDINGS: An adolescent with ADEM presented with drastic behavior and personality changes that led to her incarceration for serious charges. Acute disseminated encephalomyelitis leads to neuropsychiatric effects and can be seen with magnetic resonance imaging as a large mass effect that may result in a poor prognosis. This adolescent made a full recovery from her left facial droop, slurred speech, and left-sided hemiplegia, and her personality changes were reverted. CONCLUSIONS: Acute disseminated encephalomyelitis can present as acute psychosis; therefore, clinical suspicion is important when treating patients who have a history of past infectious brain diseases, especially encephalitis. Given the rapid onset of disease, physicians must be knowledgeable of the diagnosis and treatment of ADEM and be vigilant in finding organic causes of acute psychosis.

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department.

INTRODUCTION: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in gross morbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. This study analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed to have cellulitis, as well as the capability to differentiate cellulitis from NF. METHODS: This was a 10-year retrospective chart-review study that included emergency department (ED) patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from 0-13 for each patient with all pertinent laboratory values. Three categories were developed per the original LRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINEC score 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence of a C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC score was 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the "low risk" group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the "high risk" group. These patients missing CRP values were added to these respective groups. RESULTS: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) were moderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22 patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patients without CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, a total of 47 patients were further classified based on LRINEC score without a CRP value. More than half of the NF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to perform better in the diabetes population than in the non-diabetes population. CONCLUSION: The LRINEC score may not be an accurate tool for NF risk stratification and differentiation between cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive rate when determining NF risk stratification in confirmed cases of cellulitis and a high false negative rate in cases of confirmed NF.