Figure.4: MRI Brain shows extensive bilateral, symmetrical
punctuate foci of nearly the same size and abnormal signal intensities
giving the appearance of a starfield pattern on T2-weighted images with
restricted diffusion.
On the fourth day of admission, bilateral palpebral conjunctival
petechial spots also appeared. His pupils were isochoric, and the light
reflex was bilaterally positive. There were no meningeal signs. The
reflexes and cranial nerves were normal. He could move all 4 limbs. The
Glasgow Coma Scale score was 12: E4V2M6. Cardiac echocardiography also
revealed no evidence of patent foramen ovale.
Treatment:
One dose of hydrocortisone intravenously on day 1 of admission and
subcutaneous heparin was given in view of the pulmonary embolism. His
sensorium improved (GCS 15) with supportive measures. Respiratory
distress was managed conservatively with oxygen by mask. The patient
eventually improved with the same line of management.
Follow-up:
The patient was discharged with a repeat chest X-ray, which was normal,
and hypoxia was quick to resolve with a repeat arterial blood gas (ABG)
analysis showing normal parameters with follow-up at a multidisciplinary
clinic and rehabilitation program.
Discussions:
Fat embolism syndrome (FES) is most frequently associated with trauma
and orthopedic procedures and is characterized by major and minor
findings, as defined by Gurd [5]. Three major criteria and two minor
criteria marked by (*) in the [Table 1], was manifested in our
patient making this a strong case of FES [5,6].