Focal neurologic signs and mental status changes

New focal neurologic signs or mental status changes in a neutropenic patient should prompt vigorous evaluation. Focal signs may reflect brain parenchymal abnormalities (intracranial hemorrhage, metastases, cerebral vascular accident, brain abscesses, progressive fungal infection). Antibiotic choice should include agents that cross the blood-brain barrier. Such as third-generation Cephalosporins and Vancomycin.

Seizures may result from focal abnormalities, CNS infections, or medication toxicity. Mental status changes may be a nonspecific presenting sign of sepsis or may reflect drug effect, as well as CNS infection. Among antibiotics, imipenem and ciprofloxacin may contribute to mental status changes in the elderly or in those with renal dysfunction. In addition, antiemetics, pain medications, and sleep medications may cause mental status changes. Meningitis may occur, most commonly due to Pneumococcus, Listeria, Cryptococcus (in patients with cellular immune defects), or other fungi, but meningeal signs are uncommon. More indolent mental status changes or focal abnormalities may reflect subacute fungal infection, bacterial brain abscess, toxoplasmosis, or progressive multifocal leukoencephalopathy.

In endemic areas (See the Centers for Disease Control and Prevention Website: www.cdc.gov for maps and more information about areas in which West Nile virus transmission is occurring), West Nile virus encephalitis should be ruled out in any patient with neurologic signs, lethargy, flaccid paralysis, or multiorgan failure. Serology from blood and CSF has been the standard for diagnosis, but molecular testing may improve diagnostic yield.

Prompt radiologic imaging should be performed in cases of suspected CNS infection, as discussed above. Lumbar puncture is problematic in thrombocytopenic patients, but if strongly indicated, can be obtained with platelet transfusion support. Space-occupying lesions and cerebral edema should be ruled out first. Rapid neurologic and neurosurgical consultation should be obtained in patients with progressive symptoms.

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