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Infectious Diseases Affecting the CNS - CASES FEBRUARY 20, 2015 STANLEY D. MILLER, MD INFECTIOUS DISEASES Case #1 Presentation ◦ 32 year old AA male c/o 4 day history of frequent falls, headache, fever, diplopia, and photophobia. The symptoms progressed during that time despite an IM injection of ceftriaxone followed by 4 days of doxycycline (he was seen by his PCP c/o urgency and frequency of urination initially). Physical ◦ Temp 101.3 vital signs otherwise normal. Alert and oriented x 4 ◦ Pt. c/o diplopia with lateral gaze bilaterally, right facial droop with drooling, prominent nystagmus; greater with left lateral gaze than right. He could not cough. He was somewhat ataxic. 3/5 strength of right arm and leg, 5/5 strength of left arm and leg. Reflexes were brisk. Lab ◦ WBC 6030, segs-68, lymphs-8, monos-13, eos-1; Hgb 10.7, Platelets 397K, U/A 15-20 WBC, Sodium 131, ALP 256; CMP o/w normal. ◦ CT head without contrast “negative” ◦ Lumbar puncture was clear and colorless ◦ WBC-28 (segs-25 lymph-63 monos-12) ◦ Gram Stain-few WBCs, No organisms seen RBC-86 Protein-119 Glucose-41 (blood glucose 111) Case #1 More History ◦ He had actually not felt well for 4 months. He had c/o back pain for one month then presented to the VH-ED 2 months PTA c/o 7-10 day history of fevers, chills, cough, nausea, vomiting, and diarrhea. His liver enzymes were elevated and an U/S revealed a thick-wall GB with pericholecystic fluid. There was also a hepatic flexure “complex cyst”. He was treated with Moxifloxacin and was discharged home form the ED. ◦ After that he continued to have malaise, easy fatigability and a 10 pound weight loss. He continue to work (construction worker) but returned to his PCP when his headache worsened and he began to have frequency of urination 4 days PTA. Other ◦ He lives on a farm and raises pigs ◦ He was bitten in the hand by a Black Snake 10 months PTA ◦ He killed the snake and fed it to his pigs. Treatment and Diagnostic Studies ◦ He was initially started on IV Vancomycin, Rocephin, and Acyclovir ◦ Neurology and Infectious Diseases consultation ◦ MRI of the Brain ordered Case #1 MRI of the brain with contrast ◦ Multiple well-circumscibed ring-enhancing lesions throughout the parenchyma of the cerebrum and cerebellum, as well as the pons and brainstem. No significant peripheral edema is identified. No mass effect. The findings are suspicious for microabscesses, which could be of infectious origin. “Appearance is most suggestive of somebody who is immune suppressed”. Case #1 CT of the abdomen/pelvis/chest ◦ Nonspecific nodular opacities in the lung with upper lobe predominance, a few appear cavitary. 2.1 x 1.8 cm areas adjacent to the right psoas muscle. ◦ Interventional radiology aspirate yielded 30cc of pus that was sent for analysis (and stained acid-fast) Case #1 Treatment and clinical course ◦ Isoniazid, Ethambutol, Rifampin, Pyrazinamide, and Decadron were initiated. ◦ Most of his neurologic deficits resolved in the first 3 days of treatment (likely initially due to the Decadron). ◦ Mycobacterium tuberculosis was isolated from the right psoas pus. It was not identified in the CSF. He tested HIV negative. Final diagnosis: Tuberculous Meningitis widespread tuberculomas in brain, lung, pelvic and mediastinal lymph nodes. ◦ 10 weeks into treatment he remains asymptomatic. Repeat MRI 2/2/14 still shows innumerable ring-enhanced lesions throughout the CNS but most are smaller in size. ◦ He will likely need 18 -24 months of treatment with slow tapering of the Decadron. Case #2 Presentation ◦ A 10 year old boy was admitted to the hospital with a 2 day history of fever, headache and malaise. He was brought to the ED when his fever reached 105F and he became “confused” Physical exam ◦ Alert, but hyperactive and anxious appearing. Temp 104.5, HR 120 ◦ No nuchal rigidity. No conjunctivitis, oral lesions. Lungs clear. Abdomen soft and nontender. No focal neurologic deficits. Labs ◦ WBC 14,000 with 45% segs, 50% lymphs, 5% monos. CXR negative. Blood cultures drawn. CT of the head without contrast was “negative” Admitting Diagnosis: Viral syndrome. IV fluids and antipyretics initiated. Case #2 Hospital Course ◦ Over the next 48 hours he remained highly febrile (again up to 105F) and agitated. His parents became increasingly concerned. He began to “talk nonsense” ◦ The attending ordered a repeat CT of the head, now with contrast. ◦ Blood and urine cultures remained no growth. ◦ As a result of the CT findings; ID consult was requested and antibiotics were initiated. ◦ A lumbar puncture was performed CSF analysis ◦ Clear, slightly xanthochromic ◦ WBC (38; segs 25, lymphs 75) RBC-525 Protein-90 Glucose-84 ◦ Cryptococcal antigen: negative ◦ Gram stain: Mononuclear cells, No organisms Case #2 Initial treatment? Intravenous Acyclovir ID evaluation ◦ Dazed and babbling incoherently ◦ IV Acyclovir had already been started for suspected HSV encephalitis ◦ Patient immediately transferred to Pediatric ICU at a nearby tertiary care center. ◦ He arrested enroute and had to be brought back for intubation. He subsequently was transported to the tertiary care center and improved over the next 72 hours. He was extubated and was alert and communicative. ◦ Two hours later he rapidly decompensated, “blew his pupils”, became comatose and expired ◦ CSF PCR testing confirmed HSV Encephalitis Case #3 Presentation ◦ A 57 year old male with a history of COPD due to a 60+ pack year history of cigarette smoking was referred to the ID clinic by his pulmonologist for evaluation of “yeast” found in a BAL specimen. The bronchoscopy was performed to evaluate a left lingular mass that had been noted on CXR. He had complained of a cough with low grade fever for “months” and more recently had developed a severe headache. Physical Exam ◦ He was lying on his side on the examining table, holding his head, curled up in a ball. He was afebrile. ◦ He was thin and cachectic. Alert and oriented, but in severe distress due to his headache ◦ He could not hear out of his left ear and he had dysconjugate eye movement. ◦ No other neurologic deficits. The rest of the exam was unremarkable. Diagnostic Studies ◦ CT scan of the head without contrast was negative ◦ A lumbar puncture revealed very high opening pressure and his headache was relieved within minutes of the procedure Case #3 History ◦ He lives in a rural area and raises chickens. He regularly sweeps out the chicken coop. ◦ He takes no corticosteroids or any immunosuppressive drugs. ◦ He has had “lazy eye” since childhood but now clarifies that he can’t see out of his right eye or hear very well out of either ear. Labs ◦ WBC 13,400 with 62% PMNs, 34% lymphs, CRP 1.5 ◦ HIV antibody negative ◦ CSF was Clear and colorless: ◦ Protein 156 ◦ Glucose 24 ◦ WBC 38 (60% PMNs and 40% lymphs) Case #3 His serum and CSF cryptococcal antigen was positive at a titer of 1:1024, signifying Cryptococcal meningitis. The CSF culture grew Cryptococcus neoformans (and stained with India ink) He received 14 days of Liposomal Amphotericin B plus 5-flucytosine (induction) and was sent home on high dose Fluconazole orally. Case #4 Presentation ◦ A 23 year old male from Columbia (SA not SC) presented to the ED unresponsive and febrile. His friends could not wake him up that morning and called EMS. They related that he was fine the previous night but that he had lost a lot of weight over the last 6 months. He could not be aroused by the ED staff, UDS was negative. A stat CT of the head revealed a left hemispheric mass with a midline shift and early herniation. Decadron and mannitol were initiated and the neurosurgeon was consulted. Physical exam ◦ Physical exam revealed him to be unarousable but moaning. He was restless but would not move his right side. He appeared thin and somewhat cachectic. Oral thrush was noted. Blood work was remarkable for the following: ◦ WBC 2,100 with 75% PMNs, 6% lymphs, 18% monos, 1% eos ◦ Hemoglobin was 9.5, platelets 65,000. ◦ Liver enzymes were mildly elevated, serum creatinine was normal Case #4 Rapid HIV test was positive ◦ Calculated absolute lymphocyte count was 126 Decadron, Ceftriaxone, Metronidazole, Sulfadiazine, Pyrimethamine, and Praziquantel were initiated. His CD4 count was 12, Toxoplasmosis IgG positive, Taenia solium antibodies negative. Within 48 hours he was alert and oriented, able to move all 4 extremities. ◦ It was decided that cerebral toxoplasmosis was the most likely pathogen so treatment for that alone was continued. Case #5 Presentation ◦ 57 year old WM c/o a 1 week history of “eye irritation”, the L>R. His PCP sent him to a ophthalmologist who noted “bilateral retinitis”, L>R. The patient considered himself healthy and had not seen a doctor for 5 years. He took no medications. No history of DM, HTN, Liver disease or kidney disease. No prior episodes of retinitis. Social History ◦ He is married. No children. Works as an accountant. No tobacco, alcohol, or illicit drugs. Initial Labs ◦ ◦ ◦ ◦ WBC 6,350 with segs/57, lymphs/36, mono/4, eos/2, baso/1 Hemoglobin 13.9, platelets 194K, creatinine 0.95, Glucose 134 ALP 162, AST/ALT/T.bilirubin normal. Serum protein 9.2 UDS negative Lumbar puncture: CSF findings ◦ ◦ ◦ ◦ Normal opening pressure WBC 20 (55% segs/ 45% lymphs) Cryptococcal antigen negative VDRL nonreactive Protein 100 Glucose 80 Case #5 Other Labs ◦ ◦ ◦ ◦ ◦ HIV antibody positive CD4 count 545 CMV IgG positive/IgM negative CMV DNA by PCR <200 Serum protein electrophoresis: benign monoclonal gammopathy RPR reactive at 1:512 titer and FTAabs reactive The diagnosis of neurosyphilis in a HIV positive patient presenting with bilaterally retinitis was made. Aqueous Penicillin G 24 million unit/day was initiated. A PICC line was placed and he was discharged home after 7 days of treatment to complete the balance of 14 total days of treatment. At the time of discharge his vision had improved dramatically as did his eye exam. Case #6 Presentation ◦ 49 year black female with a 2 day history of left ear ache and a one day history of AMS. Her daughter brought her to the ED, she was aphasic and lethargic on arrival. She was afebrile but her WBC was 21,900. A stat CT of the head showed maxillary sinusitis and left mastoiditis. Physical Exam ◦ She was lethargic but arousable. Nuchal rigidity was present and she had tenderness over the left mastoid. Her left tympanic membrane was perforated with purulent drainage noted in the ear canal. Case #6 Additional history ◦ History of Migraine headaches, hypothyroidism, hypertension, hyperlipidemia ◦ No ETOH abuse, illicit drugs, head trauma Lumbar puncture: CSF results ◦ Straw colored and cloudy ◦ WBC 16620 (99%PMNs/1% lymphs) RBCs 585 Protein >300 Glucose <5 Gram stain: Gram-positive diplococci and chains of cocci Growth on BAP: Case #6 She was initially started on Vancomycin, Rocephin, and Decadron. The Streptococcus pneumonia MICs ◦ ◦ ◦ ◦ Vancomycin 0.5 Ceftriaxone Penicillin-G Levofloxacin 1.0 <=0.12 <=0.06 Vancomycin was discontinued and Ceftriaxone was given for 14 days. She recovered completely with no neurologic sequelae Diagnosis: Pneumococcal meningitis with left mastoiditis and maxillary sinusitis