A fluctuant comatose state

Excerpt

Sir: An 85-year-old woman with history of transitory ischemic attack (regressive aphasia) and complete hysterectomy for cancer was admitted to ICU for a brutal coma. She was taking daily aspirin and β-blockers for mild hypertension and ventricular arrhythmia. There was neither alcoholic nor smoking intoxication. There had been no exposure to carbon monoxide. On admission her blood pressure was 173/88 mmHg, pulse rate 60/min, and temperature 36.5 °C. She was unconscious (Glasgow Coma Scale 7) without motor and verbal spontaneity. She had oriented response to noxious stimulation. Her pupils were constricted, equal in diameter, and reactive to light. No focal deficit was observed except the absence of the lateral eyes movement. Chest radiography was normal. Electrocardiography showed sinus rhythm. Results of blood tests were: glycemia 7.2 mmol/l, natremia 134 mmol/l, calcium 2.38 mmol/l, urea nitrogen 4.2 mmol/l, and creatininemia 64 μmol/l. On room air, arterial blood gases showed PaO₂ 70 mmHg, PaCO₂ 38 mmHg, and pH 7.40. There was no effect of intravenous flumazenil (1 mg). Screening for usual sedative drugs was negative. Computed tomography of the head showed no abnormality (Fig. 1). Cerebrospinal fluid was clear without white or red cells. Proteinorachia was 0.26 g/l. Microbiological cultures remained negative. Electroencephalography showed slow bilateral waves in anterior areas with poor reactivity but no crisis. The patient was placed under mechanical ventilation.

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