Abstract
Acute necrotizing encephalopathy is a relatively rare condition in adults. We encountered an adult case of severe acute necrotizing encephalopathy that rapidly progressed to multiple organ failure and disseminated intravascular coagulation (DIC). A 24 year-old man had been treated for a sternal fracture and injuries to both knees, sustained during a motor vehicle accident. He did not have any significant medical history. He lost consciouness and his vital signs indicated shock after he had been running a temperature of 39°C and was transferred to another hospital. Soon after his arrival at the second hospital, the patient experienced convulsions, and was transferred to our institute under intubation, for more detailed evaluation and treatment. On admission, brain CT and cerebrospinal fluid examination yielded normal results. Initially, we suspected septic shock of unknown origin, and initiated treatment in the ICU. Lactic acidosis and hyperkalemia were noted, and continuous renal replacement therapy (CRRT) was initiated. The liver enzyme levels were drastically elevated, and the DIC worsened. On the second day after admission, brain herniation occurred. At this time, brain CT showed severe brain edema and bilaterally symmetrical low-density areas in the thalamus, brain stem, and cerebellum. We induced mild brain hypothermia (34°C) and administered 1 g of methylprednisolone and 180 g of mannitol for 3 days. However, on the fourth day, an electroencephalogram showed flat lines. On the 14th day after admission, the patient died of ventricular arrhythmia caused by hyperkalemia. In conclusion, clinicians should be alert to the possibility of acute necrotizing enchephalopathy, which causes impairment of consciousness, liver damage, and DIC, even in adults. The treatment of brain edema should never be delayed.
