Q&A: Encephalopathy query

Q: I recently had a case where the documented diagnoses were “paraneoplastic syndrome and possible encephalitis with references to both limbic encephalopathy and herpes simplex virus (HSV).” Treatment included intravenous immune globulin (IVIG) and steroids as well as vancomycin, meropenem, and acyclovir. The presence of an infection was unknown, and sepsis was also documented but may need to be ruled out. If I were to query for encephalopathy, would my choices of metabolic encephalopathy, septic encephalopathy, other, and undetermined be appropriate?

A: My advice would be to clarify the sepsis first, as encephalitis could be the infection which is most often caused by viruses but can also be caused by bacteria. In looking for clues to identify the infection, I start by looking for a procalcitonin level (if it was ordered) as that will give you a clue as to whether there is a bacterial infection. Then, look for results for a cerebrospinal fluid (CSF) specimen that was likely drawn in this scenario. 

Additionally, because you mentioned the patient is on acyclovir, herpes simplex virus (HSV) could be a key factor as HSV lies dormant in the spine until a stressor triggers it into activity and it often is the cause for encephalitis. In fact, it is the most common source and, depending on the patient’s comorbid condition status, and can be the most serious type of encephalitis. A question to ask yourself is: could it be that the HSV caused the encephalitis which in turn caused the encephalopathic process as well as the potential sepsis?”

Paraneoplastic syndromes are a group of rare disorders that are triggered by an abnormal immune system response to neoplasms and could be a potential etiology for encephalopathy in this case as well.

It appears very likely that the cause of the encephalopathy is multifactorial in this scenario. Based on the clinical scenario provided, the encephalopathy appears to be metabolic in nature. An easy way to distinguish metabolic versus toxic encephalopathy is to look at metabolic encephalopathy as a condition that arises within the body as opposed to toxic, which typically originates from something outside of the body (such as vapors, gases, adverse reactions or poisonings from prescribed medications or illicit drugs).

The second thing to consider with this scenario is the type of mental status symptoms the patient was experiencing. It’s important for the CDI specialist to look for the types of symptoms and recognize that they’re clues to the potential diagnoses to query for. For example, do the symptoms wax and wane or are they consistent? If symptoms wax and wane, it may be that encephalopathy is not the diagnosis the CDI specialist should be querying for and the CDI specialist would need to look for more clues or discuss the case with the provider for clarification. 

The third factor to consider is how the patient responded to treatment. Once treatment was initiated, did the patient begin to return to their mental status baseline? If the patient does not respond to treatment, either the wrong underlying etiology is being treated or it’s not an encephalopathic condition. A baseline mental status is always something the CDI specialist should look for in the medical record (especially with patients who already have an altered mental status as their normal state such as in dementia) and is also a great educational topic to engage with providers.

Based on the documentation you provided, we have IVIG (paraneoplastic syndrome), steroids (paraneoplastic syndrome, encephalitis), acyclovir (HSV), vancomycin/meropenem (sepsis, encephalitis—both needing further investigation due to your statement of sepsis may need to be ruled out as well as possible encephalitis).

Below are some suggested choices that you could tweak depending on the answers to the sepsis/encephalitis questions that are pending:

• Metabolic encephalopathy—multifactorial, due to HSV infection, paraneoplastic syndrome, and sepsis (if ruled in)
• Metabolic encephalopathy due to other, please specify
• Septic encephalopathy due to (list the underlying infection if ruled in)
• Other type of encephalopathy, please specify type and provide the underlying etiology if known
• Other, please specify
• Clinically unable to determine

These are examples of choices that you will have to determine if this style of query choices will fit within your organizational policy regarding query writing. We can expand our choices from one-word choices to better fit clinical scenarios; however, each facility has their own query policies, and the CDI specialist would need to make that determination based on their individual organization. The benefit in expanding our query choices to better fit the potential clinical scenario is that it will often provide more detail for providers to consider when answering queries. Lastly, not every query would need an expanded choice, but rather the CDI specialist can utilize these types of choices for the complicated cases such as seen in this clinical scenario.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.