Multiple-etiology delirium and catatonia in an alcoholic with tubercular meningoencephalitis
A 40-year-old male presented to the emergency department with complaints of irrelevant talk, abnormal behavior, and disorientation for four days. He had multiple generalized tonic clonic convulsions two days back. On admission he was afebrile, anxious, restless and confused with doubtful neck rigidity since he kept himself stiff and was non-cooperative during examination. He had tremors in both hands, pulse 106/min, blood pressure 146/96 mm of Hg and respiratory rate of 20/min. His remaining general physical examination was unremarkable. History revealed him to be an alcoholic for 12 years with psychological and physical dependence, with abstinence for five days. His childhood history was unremarkable. He had no past history of any medical or surgical illness except frequent cough and occasional fever for few weeks for which he took cough syrups and antipyretics directly from chemists without any consultation with doctor. He was a salesman in a grocery shop with difficulties in saving his job because of frequent absenteeism. His wife reported him to be a happy type of person during the initial three-four years of starting alcohol with friends. He gradually became alcohol-dependent, irritable, abusive and frequently aggressive to the wife and both children of 10 and 12 years of age. There was no history of any promiscuous behavior or sexually transmitted disease.\nOn mental status examination (MSE) he had altered sensorium with poor concentration, disorientation to time and place, short-term memory impairment, slurring of speech, increased psychomotor activity and irritable mood.\nOn the basis of history and MSE a diagnosis of alcohol withdrawal delirium was made and patient admitted. He was started on chlordiazepoxide 25 mg four times a day with adequate fluids and multivitamins. His hemoglobin was 12.5 gm/dl, total leucocyte count 6700/mm3 with 80% polymorphonuclear cells and 20% lymphocytes. Erythrocyte sedimentation rate was 48 mm per h and random blood sugar was 124 mg/dl. Serum bilirubin total was 1.8 mg/dl and direct was 0.9 mg/dl, Alanine amino transferase ALT was 58 and aspartate amino transferase (AST) was 97 IU/L. Renal function test, serum electrolytes, thyroid function test, lipid profile, HIV test, electrocardiogram and computed tomography scan of head were unremarkable. During second and third day of admission his psychomotor activity slightly decreased to normal. Abdominal ultrasound showed fatty liver. On fourth day morning he developed rigidity of limbs, mutism with apathetic look, open eyes and fixed gaze but no emotional responsiveness. His stuporous state was not associated with posturing or waxy flexibility. Injection lorazepam 4 mg twice a day was added to reduced dose of chlordiazepoxide 25 mg twice a day considering his condition as unusual catatonic manifestation of alcohol withdrawal. Reviewing his temperature charts revealed that he had been having an evening rise of temperature during all these days. On reexamination he had neck rigidity. Physician reference was sought and the case was transferred to the medical ward with a clinical diagnosis of alcohol withdrawal with coexistent meningoencephalitis. On further investigation his chest X-ray showed bilateral miliary shadows and cerebrospinal fluid (CSF) examination revealed protein 150 mg%, CSF sugar – 60 mg%, TLC- 60 cells/high power field, differential leucocyte counts- 100% lymphocytes, adenosine deaminase 18 U/L. Diagnosis was then revised to tubercular meningoencephalitis and treatment switched to antituberculous therapy and injection dexamethasone followed by oral steroids. After three days of starting antitubercular treatment he showed significant improvement and was discharged on Category One antitubercular treatment with advice to follow up treatment from his nearby directly observed treatment supervised (DOTS) centre as the patient was from a remote area. He did not agree to take any anticraving drugs because of poor financial status. He kept his commitment of fortnightly counseling sessions up to three months with complete abstinence and then was lost to follow-up.