After five weeks of living hell, my elderly father who had been
active and in relatively good health just got a preliminary
diagnosis of toxic encephalopathy today while in ICU.  We believe that
it was drug induced.  This is his recent medical history:

1.  Remacaid treatments in January for rheumatoid arthritis which
was just diagnosed in December. This is a new medication on the
market.
2.   February 4-11, he was lethargic with no appetite and found it
increasingly difficult to walk.
3. Feb.11th, struggling to breathe and walk with pain in the groin and
a fever of 104.7, he was taken by paramedics to the ER. They diagnosed
pneumonia and then sepsis. Symptoms were fever and increasing
hallucinations. He went in the hospital with thirty pounds of
congestion that had to be drained. After the
swelling went down, they found a gangrened left great toe and
amputated it hoping it was the site of the sepsis.  At the same time
they did an anthroscopy of his left knee which they found to be the
sepis source.
They then began an 18 day infusion of ZYVOX 600MG in D5W 300ML. He
continued to be very confused and hallucinatory, but then improved
until a syncope happened--they called it a "code." The doctors said
they did not know the cause of the syncope.  They said it was probably
a vagal episode and put him on sodium for low sodium.
3. Released to rehab the following week (after 3 weeks total)and then
he had another sycope three days later.  This time, upon return to the
hospital, they decided to do a GI workup because of a hemoglobin count
of 8 and blood in the urine.  The GI workup showed many polyps,ulcers
and diverticulitis but nothing serious and no internal bleeding.The
specialist started him on stomach meds and took him off his coumadin
for 1 week.
4. Released after 5 days to home health care.  
5. After 5 days, he was rushed to the ER with another syncope---this
one lasted for 25 minutes--the others were only 5 or 10 minutes in
duration. This was last Tues. 3/18. The ER said he was anemic with
hemoglobin down to 7 and dyhdrated.
6. Now in ICU lethargic, weak and sleeps constantly, being fed with a
feeding tube in his nose. The nurse said his electrolytes have been
"off."  The doctor does not communicate with us.
7. This afternoon,the nurse said the EEG shows a preliminary diagnosis
of toxic
encephalapathy and the infectious disease MD said his blood cultures
are clear and there is no sepsis.
I am going to now list the medicines that were on his discharge sheet
when he came home on 3/14.
He was on his 14th day of the 18 day ZYVOX infusion. (ZYVOX 600MG in
D5W 300ML):
1. lipitor 10mg 1 tab daily;
2.  folic acid 1mg 1 tab daily; 
3. prednisone 10mg two every a.m.;
4.  prednisone 5mg every evening; 
5. celexa 20mg. 1 tab daily; 
6. lasix 40mg 1 tab every 12 hrs.; 
7. k-dur 20mg 1 tab daily; 
8. vasotec 10mg 1 tab 2xday; 
9. atenolol 50 mg 1 tab daily; 
10. declomycin 30 mg 1 tab twice a day (I believe this was started the
day he came home 3/15--he became increasinly lethargic, loosing his
appetite and vomiting and then had the 25 min.syncope on tuesday
3/18--I called the druggist who said to call the doctor about the
possible interaction of the zyvox and declomycin resulting in the
lethargy);
11. prevacid 30 mg 1 tab daily; 
12. darvocet n-100 1 tab every 9 hrs as needed; 
13. allopurinol 300mg 1 tab daily;
 and one other that I am unable to read.  

Any advice and direction you could give such as questions to ask,
specialists to ask for, places to go for medical care would be greatly
appreciated.  This dear Dad has always helped others and now he is in
desperate need of help. With sincere thanks.

Hello - thanks for asking your question. 
 
Please understand my limitations over the internet as I have neither
met nor examined you. This information is for patient education only.
Please see your personal physician for further evaluation.

I will now discuss the various causes of toxic encephalopathy.  You
may want to discuss these issues with your personal physician.

Acute toxic-metabolic encephalopathy (TME), which encompasses delirium
and the acute confusional state, is a condition of acute global
cerebral dysfunction not due to primary structural brain disease.

TME is usually a consequence of systemic disorders, and therefore the
causes of TME are diverse. Most TME is reversible, making prompt
recognition and treatment important.

Septic encephalopathy — Septic encephalopathy is the most common cause
of TME, and its presence and severity correlate with increased
mortality.  The EEG is usually diffusely slow, and as the
encephalopathy worsens there may be triphasic waves, and a
burst-suppression pattern in severe cases (you may want to compare
this with the pattern on your EEG).

Hepatic encephalopathy - Acute hepatic encephalopathy associated with
marked cerebral edema is seen in patients with the acute onset of
hepatic failure.
Chronic hepatic encephalopathy occurs in subjects with chronic liver
disease.

Uremic encephalopathy — TME is a sign of advanced renal failure. 
Early clinical features of uremic encephalopathy include lethargy,
irritability, disorientation, hallucinations, and rambling speech. 
The EEG in uremia reflects the severity of encephalopathy. The most
common EEG finding is prominence of slow waves. Intermittent frontal
rhythmic theta activity and paroxysmal, bilateral, high voltage delta
waves also are frequent, and triphasic waves may appear in the frontal
regions (again, you may want to compare this with the pattern on your
EEG).

Hyponatremia — Hyponatremia (low sodium), a common cause of TME, is
most often due to the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH) or a decrease in effective circulating
blood volume.  Confusion, disorientation, agitation, delirium,
lethargy, muscle cramps, and generalized weakness are common. With
advancing hyponatremia, the level of consciousness declines and
generalized tonic-clonic seizures appear.

Hypernatremia — Hypernatremia (high sodium) is due to increased
insensible water losses, decreased thirst or access to water, infusion
of large volumes of saline or bicarbonate, or diabetes insipidus.

Other electrolyte abnormalities — Other electrolyte abnormalities that
can produce encephalopathy include hypo- or hypercalcemia,
hypomagnesemia, and hypophosphatemia.

Hypoglycemia — Hypoglycemia can produce a myriad of neurologic signs
and symptoms. Hypoglycemia results from the use of insulin or
hypoglycemic agents, alcoholism, and/or chronic liver disease.

Hypoxic-ischemic encephalopathy — Hypoxic-ischemic encephalopathy is a
straightforward diagnosis following an obvious precipitating event
such as cardiac arrest with prolonged resuscitation efforts.  Clinical
findings range from subtle memory difficulties to coma.

Steroids - Corticosteroids may cause insomnia, irritability, impaired
concentration, and mood changes including a florid steroid psychosis
(note that prednisone is one of the medications on the list).

In terms of the next step, it depends on the cause of the
encephalopathy.  A good first step would be to discontinue all
psychotropic medications (discuss this with your personal physician).

Next, I would ensure that all electrolytes are normalized (i.e.
sodium, potassium, calcium etc.) - this can definitely contribute to
encephalopathy.

If the cause is secondary to the infection, then the best thing to do
is treat the infection appropriately (as you are doing wtih Zyvox) and
reassess on a daily basis.

As for consultations, a neurology referral would be a good place to
start.  A neurologist would be best able to address the encephalopathy
and the factors contributing to it.

This answer is not intended as and does not substitute for medical
advice - the information presented is for patient education only.
Please see your personal physician for further evaluation of your
individual case.

Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.      
            
Thanks,             
Kevin, M.D.      
    
Search strategy:     
No internet search engine was used in this answer.  All sources are
from physician-written and peer-reviewed sources.
   
Bibligraphy:  
Chalela et al.  Acute toxic-metabolic encephalopathy in the intensive
care unit.  UptoDate, 2002.

There are times when words cannot express the gratitude one feels. 
This is one of those times. You have been so very kind. I wish only
the most wonderful of life's blessings to you.

Hi -

Miraculous things can happen with radical diet changes that involve
heavy juicing and herbal intake.  I have personally seen people be
healed from  diabetes, arthritis, acid reflux disease, and other
ailments -- things that would normally be classified as incurables. 
If you're interested, let me know, and I can provide some sources you
could look into.

jbf777-ga
GA Researcher

Thank you.  Yes, I would like to access the list of juices and dietary 
advice you speak of.

Thank you for your kind comments.  I hope all goes well with your father.

Kevin, M.D.