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Advice requested coma patient Mozambique

Eric Regouin e.j.m.regouin at ikc.agro.nl
Thu Feb 13 06:26:01 EST 1997

Dear Sir / Madame,

We are desperately seeking information/ideas/suggestions
over the possible cause for the coma in which our brother is since
16/12/96. More important than the cause we are looking for
suggestions for treatment of the spastic contractions which he has
almost constantly. If you by any chance have ever been faced with a similar
case or know of some other doctor who could give us some information
could you please help us by writing back to us as soon as possible. Do
not write to this Newsgroup (only) as we have no access to it.

return address: pvictor at zebra.uem.mz

The following is a description of his case: 
Manuel Julien is a medical doctor (pediatritian and nutritionist) working at the
central hospital in Maputo until the day he fell into a coma. He is 41
years old, mixed race (white, black and indian). He was a healthy
person only having asthma and allergy. Simptomatology: He began at 
20:30h of 15/12/96 having cold chills and feeling tired when he was
working during his night shift. He decided to have his glycemy and
plasmodium checked. The values of this glycemy were normal and the
plasmodium negative. His blood pressure was 130/80, regular pulse
(86), no fever or other symptoms. At 9h of the 16th december he still
had the same complaints. He ate (meat) and drank a glass of milk. He
than took a nap until 12h. When he woke up he mentioned being hungry
and asked for pork ribs and chips which he ate. 20 min later he asked
for a coca-cola which his wife went to fetch. When she came back he
was unconscious. Within a few minutes he was in a deep coma. 15 min
later he had his first SEIZURE (generalised tonic clonic). He was then
sent to a private clinic in Maputo where glycemic and plasmodium
measurements were taken. Those were found normal again. He was given 2
amp. of dextrose hipertonic in a glycose sorum. He had 3 more seizures
of short duration without relaxation of de sphincters. He was given
diesepan, fenobartital and dormicum but continued restles. Due to lack
of adequate instruments for further investigation in Mozambique it was
decided that he should be evacuated to South Africa. Aproximately 7
hours after he fell into a coma he was transported by plane to
Johannesburg. During the trip there were no seizures, his temperature
raised for the first time 40 minutes after departure (37,6ºC). The
trip lasted 1 hour. When he arrived at the clinic (Milpark hospital)
the following tests were made: FBC/PLT A/H, Urea, Malaria,
Electrolytes, Creatinine. The results were all negative except for the
level of glucose in the blood. He was given intravenous glucose. In
the first hours of the 17th he was found to have high as well as low
(0.6 mmol/l, Lumbar Puncture) values of glycemy which led the doctors
to consider the possibility of diabetis. However this diagnosis was
invalidated since a new test was made (Dec.18th) and normal values
were obtained. Until the 22nd all other tests made showed no
abnormality (F.A.T., herpes, M CSFMCS, insulin (14.0 on 17th dec),
glucose (8.3 mmol/l on 18th dec), liver functions, thyroid function
tests). He has had respiratory infections from time to time while
being nursed in the clinic in South Africa. It is important to note
that on the day of his arrival he had 4 more seizures and 3 the next
day despite the fact that anticonvulsives were being administered. He
never suffered from epilepsy before. Since he fell in coma he has not
talked again. He stayed on a value 3 on the Glasgow Coma Scale until
the 10th day. On the 10th day he began to react to pain and had a few
reflexes (e.g. flexion of both inferior limbs while simultaneously he
opened his eyes).Those signals were mantained until the 23rd without
improvement or regression. On the 23rd he had 2 seizures and went back
to value 3 on the Glasgow Coma Scale. On the 2nd Januari he had 1
seizure. From the 37th day until now he opens his eyes spontaneously,
reacts to pain, the mimic of the face is maintained (e.g. as reaction
to pain), involuntary contractions of the jaws. The tone is incresed
in his arms and legs and he frequentely has clonic jerking of arms.
Since 39th day he has had no more fever (til then his temperature
raised frequently). His blood pressure varies but remains within
normal range, pulse > 100 from day 15. He has neither signs of
distrophy/atrophy of de musclus nor of de skin! 46th day: He has
almost constantly clonic jerking of arms and legs especially early in
the morning and in the evening. Until three days ago on his left side.
Since the day before yesterday (30th of January) predominantely on his
right side. Those spastic contractions cause hyperextension of the
neck, the superior limbs and flexion of the inferior limbs. 50th day:
he started developing new symptoms: nystagmus several times during the
day with dilation of the pupils which lasted approximately 3 minutes
each time. On one occasion, immediately after a nystagmus his lips and
jaws started shaking while the rest of his body remained still. A sort
of spasm limited to the face. This was immediately followed by total
relaxation of the whole body which never happened before. At the same
time he tryed to lift his head. 51 day: nystagmus again. Reaction to
pain diminished. Till then he reacted to pain by flexion of the
inferior limbs, tears on the side of the contraction (???). Pupils
equal- no papilloedema. Corneal reflex is present, the oculocephalic
reflex is present. Cough reflex is present. Results of CT-scans and
MRIs: He had CT-scans and MRI scans performed on a few occasions since
his admission and these investigations have all been normal. The MRI
on 14th Januari showed degeneration of various cerebral sites, notably
the basal ganglia. Ventricles slightly increased. The sulci aronund
the brain were also prominent. CT-scan on 2nd February showed atropy
of the cortex. 3rd ventricle and lateral ventricles dilated. Lumbar
punctures were performed on 3 occasions and these were all essentially
normal, except the first which showed the glucose in the cerebro
spinal fluid to be very low at 0,5. He also had an EEG performed and
it showed a generalised abnormality.

Today is 54th. He still has spastic contractions the whole day long.
However, now those contractions cause a very shalow breathing,
sweating acompanied by  opening widely his  eyes.  The treatment
given against those spastic contractions has not yet shown effective. The
following has been tried: INTRAVENOUS CLONOZEPAN and when the spasms
are more intense DIEZEPAN is added.

Since the beginning the treatment of  the seizures has been the

* Sodium Valproate: initially 2000 mg/day, now 1600mg/day
* Phenytoin:  from the beginning until now 600mg/day

Anxiously awaiting a reaction we thank you for your attention,

Victor Julien and Manuela Julien

Return address:  pvictor at zebra.uem.mz

p.s. If you need more detailed and accurate information we will see that a
medical doctor answer all your questions. We are aware of the fact
that we probably did not provide all the necessary information.

Maputo, 12th of February 1997

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