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A woman with a
bifrontal headache
and confusion
2013 July-August Featured Case
DR M Haghighi MD
History of Present Illness
• A woman in her thirties developed a progressive
bifrontal headache associated with a temperature to
100.0°F (37.8°C). She went to sleep in the late
afternoon.
• Approximately 24 hours later, her husband found her
difficult to arouse, nonverbal and non-interactive. She
was unable to arise from bed, answer questions or
follow commands, and appeared confused.
Past Medical History
• She had previously been well.
Medications
• None.
Epidemiological
History
• She lived with her husband and young daughter, and
worked as a housekeeper. She did not drink alcohol,
smoke tobacco, or use illicit drugs.
Physical
Examination
• The patient appeared somnolent, arousable to painful
stimuli, and unable to follow commands consistently.
The blood pressure was 143/60 mm Hg, pulse 59 beats
per minute, temperature 38.3°C (101.0°F), respirations
20 beats per minute, and oxygenation 98% while
breathing room air.
• On neurological examination, the pupils were
symmetric and sluggishly reactive from 4mm to 3mm;
extra-ocular movements were grossly intact. She was
able to open her eyes and moved all four extremities
spontaneously. Deep tendon reflexes were 2+ and
symmetric bilaterally. The remainder of the
examination was otherwise normal.
Studies
• Her white blood cell count was 17,900 per cubic
millimeter (reference range 4,500-11,000) with an
absolute neutrophil count of 14,770 cells per cubic
millimeter (ref. 1800-7700). The hemoglobin and
platelet counts were normal. Other routine laboratory
tests including blood levels of electrolytes, and tests of
coagulation, renal function and liver function were
normal. Serum toxicology panel was negative.
• Urinalysis revealed a specific gravity of 1.030, trace
ketones, trace urobilinogen, 2+ protein, and 10-20 red
blood cells and 3-5 white blood cells per high power
field. Culture of the urine and blood were obtained,
and were sterile.
WHAT IS YOUR
RECOMMENDATION?
• A chest radiograph was normal. Computed
tomography (CT) of the head, performed without the
administration of contrast revealed enlargement of the
lateral and third ventricles consistent with
hydrocephalus.
CT of the brain, sagittal view, without
contrast
WHAT IS YOUR PLAN?
Clinical Course
• The patient was intubated and bilateral external
ventricular devices were placed emergently, with
improvement in the severity of hydrocephalus on
follow-up CT imaging.
• Analysis of cerebral spinal fluid (CSF) obtained from
the external ventricular drains revealed a glucose level
of 79 mg/dl (reference range 50-75), a normal total
protein level; 1150 red blood cells per cubic
millimeter, and 2 white blood cells per cubic
millimeter.
WHAT IS YOUR NEXT
STEP?
• Dexamethasone (4mg every 6 hours), levetiracetam,
ceftriaxone, vancomycin, and acyclovir were
administered.
• MRI of the cervical, thoracic, and lumbar spine were
negative. An ophthalmologic examination revealed no
evidence of ocular involvement.
• Testing for serum HIV antibodies, interferongamma release assay, and mycobacterial DNA
from the cerebrospinal fluid were negative.
Cultures of the cerebrospinal fluid for bacteria,
fungi, and mycobacteria were sterile.
WHAT IS YOUR
RECOMMENDATION?
CT of the brain, sagittal view, without
contrast
• (CT) of the head, performed without the
administration of contrast revealed enlargement of the
lateral and third ventricles consistent with
hydrocephalus , and
• a fluid-filled vesicular structure in the frontal horn of
the left lateral ventricle near the foramen of Monroe
with a soft-tissue density inside the cyst, and calcified
densities scattered throughout the supratentorial brain.
• On the second hospital day, magnetic resonance
imaging (MRI) of the brain was performed with the
administration of contrast .
DIFERENTIAL DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
• Tuberculous meningitis caused by Mycobacterium tuberculosis
• Echinococcus spp.
• Aspergillus spp.
• Sarcoidosis
• Malignancy
• Cryptococcal meningitis
• Vasculitis
• Coenurosis
• Brain Abscess
• Toxoplasmosis
• MRI of the brain revealed a nonenhancing multilobed
cystic mass (28.4mm in its greatest dimension) within
the left lateral ventricle and numerous calcified foci
throughout the cerebral hemispheres, as were seen on
CT.