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.