CASE HISTORY/ EXAMINATION
A 26-year-old married male presented at a community hospital with
complaints of headache, slurred speech, and recurrent focal onset
seizures with multiple episodes of loss of consciousness for 2 days.
After the initial evaluation, he developed fever and exhibited a decline
in the Glasgow Coma Scale (GCS-7, E3V1M3) necessitating intubation.
Following the initial intubation, the patient was extubated but later
required reintubation due to respiratory distress caused by
hospital-acquired pneumonia. Subsequently, he was airlifted to a
tertiary center in the capital, where he remained in the Intensive Care
Unit (ICU). He was then referred to our center for further management.
Examination at our center revealed Glasgow Coma Scale (GCS)of E4VtM6. On
neurological examination, the patient was aphonic but exhibited normal
reading and verbal comprehension. Communication was maintained through
writing and signs. Corneal, pupillary, and extraocular movements were
intact. Jaw jerk was exaggerated. Pupils were reactive to light
bilaterally. He was unable to whistle and could not stick out tongue or
chew. He had normal mouth opening and could swallow water. Tongue was
stationary in midline with no atrophy or fasciculation. Palatal movement
was absent on voluntary command. Spontaneous smiling, yawning, palatal,
laryngeal and blink reflexes were present but gag reflexes was absent.
His strength was 4+ out of 5 across all joints of upper and lower limbs
on motor examination. Deep tendon reflexes were preserved. Plantar
response was down-going. Coordination, sensory examination, and
extrapyramidal signs were within normal limits.