A woman with a A woman with a bifrontal headache and bifrontal headache and

confusionconfusion2013 July-August Featured Case2013 July-August Featured Case

DR M Haghighi MDDR M Haghighi MD

History of Present IllnessHistory of Present Illness

• A woman in her thirties developed a A woman in her thirties developed a progressive bifrontal headache associated progressive bifrontal headache associated with a temperature to 100.0°F (with a temperature to 100.0°F (37.8°C37.8°C). She ). She went to sleep in the late afternoon.went to sleep in the late afternoon.

• Approximately 24 hours later, her husband Approximately 24 hours later, her husband found her found her difficult to arousedifficult to arouse, , nonverbal and nonverbal and non-interactivenon-interactive. She was unable to arise from . She was unable to arise from bed, answer questions or follow commands, bed, answer questions or follow commands, and appeared and appeared confusedconfused. .

Past Medical HistoryPast Medical History

• She had previously been well.She had previously been well.

MedicationsMedications

• None.None.

Epidemiological HistoryEpidemiological History

• She lived with her husband and young She lived with her husband and young daughter, and worked as a housekeeper. daughter, and worked as a housekeeper. She She did not drink alcohol, smoke tobacco, or did not drink alcohol, smoke tobacco, or use illicit drugs.use illicit drugs.

Physical ExaminationPhysical Examination

• The patient The patient appeared somnolentappeared somnolent, arousable to , arousable to painful stimuli, and unable to follow painful stimuli, and unable to follow commands consistently. The blood pressure commands consistently. The blood pressure was 143/60 mm Hg, pulse 59 beats per was 143/60 mm Hg, pulse 59 beats per minuteminute, temperature 38.3°C (101.0°F), , temperature 38.3°C (101.0°F), respirations 20 beats per minute, and respirations 20 beats per minute, and oxygenation 98% while breathing room air. oxygenation 98% while breathing room air.

• On neurological examination, the pupils were On neurological examination, the pupils were symmetric and sluggishly reactive from 4mm symmetric and sluggishly reactive from 4mm to 3mm; to 3mm; extra-ocular movements were extra-ocular movements were grossly intactgrossly intact. She was able to open her eyes . She was able to open her eyes and moved all four extremities spontaneously. and moved all four extremities spontaneously. Deep tendon reflexes were 2+ and symmetric Deep tendon reflexes were 2+ and symmetric bilaterallybilaterally. The remainder of the examination . The remainder of the examination was otherwise normal. was otherwise normal.

StudiesStudies

• Her white blood cell count was 17,900 per Her white blood cell count was 17,900 per cubic millimeter (reference range 4,500-cubic millimeter (reference range 4,500-11,000) with an absolute neutrophil count of 11,000) with an absolute neutrophil count of 14,770 cells per cubic millimeter (ref. 1800-14,770 cells per cubic millimeter (ref. 1800-7700)7700). The hemoglobin and platelet counts . The hemoglobin and platelet counts were normal. Other routine laboratory tests were normal. Other routine laboratory tests including blood levels of electrolytes, and including blood levels of electrolytes, and tests of coagulation, renal function and tests of coagulation, renal function and liver function were normal. Serum liver function were normal. Serum toxicology panel was negative.toxicology panel was negative.

• Urinalysis revealed a specific gravity of 1.030, Urinalysis revealed a specific gravity of 1.030, trace ketones, trace urobilinogen, 2+ protein, trace ketones, trace urobilinogen, 2+ protein, and 10-20 red blood cells and 3-5 white blood and 10-20 red blood cells and 3-5 white blood cells per high power field. Culture of the urine cells per high power field. Culture of the urine and blood were obtained, and were sterile. and blood were obtained, and were sterile.

WHAT IS YOUR WHAT IS YOUR RECOMMENDATION?RECOMMENDATION?

• A chest radiograph was normal. Computed A chest radiograph was normal. Computed tomography (CT) of the head, performed tomography (CT) of the head, performed without the administration of contrast without the administration of contrast revealed revealed enlargement of the lateral and enlargement of the lateral and third ventricles consistent with third ventricles consistent with hydrocephalus.hydrocephalus.

CT of the brain, sagittal view, without CT of the brain, sagittal view, without contrastcontrast

WHAT IS YOUR PLAN?WHAT IS YOUR PLAN?

Clinical CourseClinical Course

• The patient was intubated and The patient was intubated and bilateral bilateral external ventricular devices were placed external ventricular devices were placed emergentlyemergently, with improvement in the , with improvement in the severity of hydrocephalus on follow-up CT severity of hydrocephalus on follow-up CT imaging.imaging.

• Analysis of cerebral spinal fluid (CSF) Analysis of cerebral spinal fluid (CSF) obtained from the external ventricular drains obtained from the external ventricular drains revealed a glucose level of 79 mg/dl revealed a glucose level of 79 mg/dl (reference range 50-75), a (reference range 50-75), a normal total normal total protein level; 1150 red blood cells per protein level; 1150 red blood cells per cubic millimeter, and 2 white blood cells cubic millimeter, and 2 white blood cells per cubic millimeter.per cubic millimeter.

WHAT IS YOUR NEXT WHAT IS YOUR NEXT STEP?STEP?

• Dexamethasone (4mg every 6 hours), Dexamethasone (4mg every 6 hours), levetiracetam, levetiracetam, ceftriaxone, vancomycin, and ceftriaxone, vancomycin, and acyclovir were administered.acyclovir were administered.

• MRI of the cervical, thoracic, and lumbar MRI of the cervical, thoracic, and lumbar spine were negative. An ophthalmologic spine were negative. An ophthalmologic examination revealed no evidence of ocular examination revealed no evidence of ocular involvement.involvement.

• Testing for serum HIV antibodies, Testing for serum HIV antibodies, interferon-gamma release assay, interferon-gamma release assay, and mycobacterial DNA from the and mycobacterial DNA from the cerebrospinal fluid were negative. cerebrospinal fluid were negative. Cultures of the cerebrospinal fluid Cultures of the cerebrospinal fluid for bacteria, fungi, and for bacteria, fungi, and mycobacteria were sterile.mycobacteria were sterile.

WHAT IS YOUR WHAT IS YOUR RECOMMENDATION?RECOMMENDATION?

CT of the brain, sagittal view, without CT of the brain, sagittal view, without contrastcontrast

• (CT) of the head, performed without the (CT) of the head, performed without the administration of contrast revealed administration of contrast revealed enlargement of the lateral and third ventricles enlargement of the lateral and third ventricles consistent with hydrocephalus , andconsistent with hydrocephalus , and

• a fluid-filled a fluid-filled vesicular structure in the frontal vesicular structure in the frontal horn of the left lateral ventriclehorn of the left lateral ventricle near the near the foramen of Monroe with a soft-tissue density foramen of Monroe with a soft-tissue density inside the cyst, and calcified densities inside the cyst, and calcified densities scattered throughout the supratentorial brain.scattered throughout the supratentorial brain.

• On the second hospital day, magnetic On the second hospital day, magnetic resonance imaging (MRI) of the brain was resonance imaging (MRI) of the brain was performed with the administration of performed with the administration of contrast .contrast .

DIFERENTIAL DIFERENTIAL DIAGNOSISDIAGNOSIS

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

• Tuberculous meningitis caused by Tuberculous meningitis caused by Mycobacterium Mycobacterium tuberculosistuberculosis

• EchinococcusEchinococcus spp. spp.

• AspergillusAspergillus spp. spp.

• SarcoidosisSarcoidosis

• MalignancyMalignancy

• Cryptococcal meningitisCryptococcal meningitis

• VasculitisVasculitis

• CoenurosisCoenurosis

• Brain AbscessBrain Abscess

• ToxoplasmosisToxoplasmosis

• MRI of the brain revealed a nonenhancing MRI of the brain revealed a nonenhancing multilobed cystic mass (28.4mm in its multilobed cystic mass (28.4mm in its greatest dimension) within the left lateral greatest dimension) within the left lateral ventricle and numerous calcified foci ventricle and numerous calcified foci throughout the cerebral hemispheres, as were throughout the cerebral hemispheres, as were seen on CT.seen on CT.