Table 1.

Clinical and Biochemical Summary of Events.

Day	Events and Management	Investigations	Antiepileptic and Antibiotic changes
Day 1	Presentation to ED via ambulance for 2x generalised tonic clonic seizures Respiratory Rate: 20 breaths/min Heart Rate: 110 bpm, sinus rhythm Blood Pressure: 140/85 mmHg Temperature: 37.3 °C Oxygen Saturation: 94% with 0.21 FiO2 Admitted to ward	CT Brain: No intracranial haemorrhage or mass. Haemoglobin: 126 g/L (130-180 g/L) White Cell Count: 8.9 × 109/L (4.0-11.0 × 109/L) Platelets: 198 × 109/L (150-450 × 109/L) C-Reactive Protein: 27.5 mg/L (<3.0 mg/L) Sodium: 128 mmol/L (135-145 mmol/L) Potassium: 3.3 mmol/L (3.5-5.2 mmol/L) Corrected Calcium: 2.54 mmol/L (2.15-2.55 mmol/L) Magnesium: 0.73 mmol/L (0.70-1.10 mmol/L) Creatinine: 56 umol/L (60-100umol/L) eGFR: >90 ml/min/ 1.732 (>90 ml/min/ 1.732) Creatine Kinase: 108 U/L (<201U/L) Liver Function tests (LFTs): Bilirubin: 58 umol/L (<25umol/L) ALP: 779 U/L (40-130 umol/L) GGT: 1532 U/L (<51umol/L) ALT: 49 U/L (<51umol/L) AST: 99 U/L (<41U/L) Albumin: 31 g/L (35-50 g/L) Arterial Blood Gas: pH: 7.37 (7.35-7.45) pCO2: 55 mm Hg (35-46 mmHg) pO2: 30 mm Hg (80-100 mmHg) Lactate: 1.3 mmol/L (<1.5 mmol/L)	Midazolam IM 10 mg with Ambulance Clonazepam PO 0.5 mg Levetiracetam IV 1 g Levetiracetam IV 500 mg BD ongoing
Day 2	MET call for partial tonic clonic seizure lasting >20 mins Transfer to ICU: Grade 1 intubation and mechanical ventilation with propofol and rocuronium. Metaraminol requirements post intubation for BP maintenance Titrated propofol and fentanyl to effect Thiamine and Lactulose commenced	MRI Brain: T2 hyperintense signal within the right medial temporal lobe and thalamus with minor diffusion restriction and vasogenic oedema suggesting viral encephalitis. Chronic small vessel ischaemia. Lumbar Puncture: performed, results pending Hyponatraemia: 124 Hypercalcaemia: 2.81 Ammonia level: 63 umol/L (11-45umol/L). Bilirubin: 58 Creatinine: 56 eGFR: >90	MET team gave Midazolam IV 10 mg Phenytoin loaded IV 20 mg/kg Phenytoin IV 300 mg daily ongoing Ceftriaxone IV 2 g BD Acyclovir IV 10 mg/kg TDS and single dose dexamethasone IV 10 mg commenced for potential encephalitis Metronidazole commenced for potential biliary sepsis
Day 3	Dexmedetomidine infusion commenced. Metaraminol required for 1 day. Internal jugular central venous line, vascular catheter and arterial line inserted	Ultrasound Abdomen and Renal tract: potential hydronephrosis	Increased levetiracetam to 1 g BD IV Midazolam infusion commenced Benzylpenicillin IV 1.8 g 4hourly commenced for potential Listeria infection
Day 4	Noradrenaline infusion commenced Developed Hypotension with a MAP of 55 Sedation break: 3-4 min of seizure activity, self-ceased. Acute kidney Injury (AKI)	Lumbar Puncture: Protein elevated 0.62, normal glucose 2.9. No bacteria seen and nil growth after 48hrs CSF HSV/EBV/VZV/ Flavivirus PCR: added on tests CSF Paraneoplastic antibodies and anti-NMDA testing: added on tests HIV serology: pending Ammonia level 44 Creatinine peaked: 269 eGFR: 21 Blood cultures: no growth	Administered phenobarbitone IV 60 mg single dose Decreased levetiracetam to 500 mg BD due to AKI Ceased ceftriaxone and metronidazole. Decreased acyclovir dose to IV 750 mg BD due to AKI
Day 5	Noradrenaline infusion ceased Hypotension resolving Sedation break: midazolam infusion ceased. Observed partial seizures in right lower limb	EEG: consistent with encephalitis Hyponatraemia: Na 128 with polyuria	Given Midazolam IV 5 mg 5 min after seizure activity. Midazolam infusion restarted. Current regime: Phenytoin 300 mg mane IV Levetiracetam 500 mg BD IV Carbamazepine 550 mg single dose IV
Day 6	IV dextrose given Vascular catheter removed	Hypernatraemia: Na 158 CSF PCR: Parechovirus detected CSF HSV/EBV/VZV/ Flavivirus PCR: negative CSF Paraneoplastic antibodies and anti-NMDA testing: negative HIV serology: negative	Sodium Valproate IV 800 mg BD commenced Benzyl penicillin and Acyclovir ceased
Day 7	Dexmedetomidine causing hypotension. Noradrenaline restarted Midazolam and fentanyl ceased Thiamine ceased Lactulose decreased	Creatinine: 138 eGFR: 47 Bilirubin: 11	Levetiracetam increased to 1 g BD
Day 8	Transferred to tertiary metropolitan hospital ICU		Sodium Valproate IV 800 mg BD Clonazepam IV 0.5 mg BD Phenytoin IV 500 mg daily Levetiracetam IV 1.5 g BD
Day 9		EEG : epileptiform discharge right hemisphere posterior quadrant and temporal region and contralateral occipital lobe VRE swabs: pending results
Day 10	Episode of tachycardia HR 115 and febrile 38.5	EEG: mild encephalopathy, frequent epileptiform discharge from right hemisphere, poorly formed background rhythms and frequent delta slowing over right hemisphere suggestive of structural abnormality Blood cultures: pending results	Ceftriaxone started IV 1 g daily
Day 11	Increasing noradrenaline requirements	EEG: frequent focal epileptic activity over right hemisphere CT Chest Abdomen Pelvis: 6.1 cm liver mass, left biliary dilatation, right sided biliary stents, small right pleural effusion	Clonazepam IV 0.5 mg BD increased to TDS
Day 12	IV dextrose	VRE vanB: positive Hypernatraemia: 152	Ceftriaxone increased IV 2 g daily Metronidazole IV 500 mg BD and Teicoplanin started
Day 14	Extubated	EEG: right posterior quadrant and frontotemporal changes. Not in electrographic status epilepticus
Day 15	Hypoactive delirium Lactulose commenced Quetiapine commenced	Ammonia 59 LFT: cholestatic profile worsening
Day 16			Phenytoin changed from IV 500 mg daily to oral Levetiracetam IV 1.5 g BD changed to oral Sodium valproate changed from IV 800 mg BD to oral Ceftriaxone, Teicoplanin and metronidazole ceased Augmentin Duo Forte 500 mg/125 mg and Ciprofloxacin 500 mg BD commenced
Day 17			Clonazepam IV 0.5 mg TDS changed to oral Ciprofloxacin ceased
Day 18	Lactulose ceased		Clonazepam decreased to oral 0.5 mg BD
Day 20		EEG: right temporal discharges of broad field (less frequent than EEG on 9/10/17). Background is slow, consistent with mild encephalopathic process
Day 24		CT Brain: nil new findings
Day 27		EEG: nil epileptiform abnormalities, improved from EEG on 19/10/17. Mild diffuse slowing
Day 30		Ascitic tap: performed. Cytology consistent with cholangiocarcinoma
Day 31		VRE vanB: still detectable
Day 35	MET call: post procedure tachypnoea and tachycardia Post-procedure pancreatitis	ERCP: intra-ductal stent stenosis, clearance of right anterior duct stent of distal stones/sludge, improved on cholangiogram Lipase: 1578	Levetiracetam, phenytoin and sodium valproate changed to IV in setting of fasting patient Augmentin Duo Forte ceased Tazocin IV 4.5 mg 8hourly and Teicoplanin IV 800 mg 24 hourly commenced
Day 38			Phenytoin changed from 500 mg IV daily to 300 mg IV daily
Day 39			Phenytoin reduced to oral 300 mg daily
Day 41		EEG: normal EEG	Clonazepam reduced from oral 0.5 mg BD to 0.25 mg BD Levetiracetam changed to oral
Day 42			Sodium valproate changed to oral 800 mg BD Teicoplanin and Tazocin ceased
Day 43			Changed to Augmentin Duo Forte
Day 44	Transferred to rehabilitation		On transfer: Clonazepam PO 0.25 mg BD Phenytoin PO 300 mg daily Levetiracetam PO 1.5 g BD Valproate PO 800 mg BD
Day 47			Clonazepam changed to PO 0.25 mg nocte
Day 51			Augmentin Duo Forte ceased
Day 52			Clonazepam ceased
Day 63	Discharged home		On discharge: Phenytoin PO 300 mg daily Levetiracetam PO 1.5 g BD Valproate PO 800 mg BD
	Out-patient	Ascitic tap: performed
	Out-patient	Ascitic tap: performed
	Oncology clinic follow-up	CT Abdomen: progressive omental disease and liver metastases	Discharged with GP follow-up for symptom management