Case Discussion: CNS infection

• MA
• 33/F
• No known co-morbid conditions
• Right-handed
• Lives in Bulacan with daughter and husband
• Housewife

• Source of history: sister

• History started 1 month PTC (Aug 16, 2014) when
patient started having recurrent colds and headaches,
associated with dizziness and undocumented fever.

• Patient was seen at a local hospital in Bulacan and

diagnosed with Systemic Viral Illness. Treatment was
unrecalled. (Antibiotics? Antipyretics?)

• Four days later (Aug. 20), patient started having right-

sided facial asymmetry and slurring of speech.
Generalized, throbbing headache was now associated
with vomiting.
• On Aug 21-26, patient was admitted at a local
hospital and was managed as a case of stroke.
No imaging studies were done. She was
started on aspirin, statin and an
antihypertensive. She was discharged stable,
however the headache persisted.

• On Aug 29, there was note of decreased

verbal output, unsteady gait, incontinence,
and generalized weakness.

• An MRI of the brain was requested prior to

transfer to SLMC. (Sept 11, 2014)
QUESTIONS/ CLARIFICATIONS?
• Pt is drowsy, wakefulness is sustained for an
average of 10- 20 seconds, follows commands,
oriented to person but not to place and time,
can name objects, with dyscalculia, impaired
attention span (cannot completely spell name
forward and back), impaired immediate and
recent recall, impaired fund of information,
judgement, insight and abstract reasoning

• MMSE: 17/30
• 110/80, 90’s regular with strong pulses, 20
breaths per min, afebrile
• Oral mucosa and tongue were dry

• Intact sense of smell on both nostrils

• Pupils are isocoric at 2-3 mm BRTL
• No visual field cuts
• VA: 20/50 OU
• Funduscopy: bilateral papilledema
• Full EOMs
• Brisk corneal reflex bilateral
• right central facial palsy
• Intact gross hearing
• Weak gag reflex on the left
• Equal palatal elevation
• Tongue midline

• MST: 4/5 on all

• Briskly withdraws to pain on all
• (+) nuchal rigidity
• (-) dysmetria, dysdiadochokinesia, nystagmus
• (+) head-bobbing and truncal instability
• Unable to sit and stand without support
• Patient was admitted, placed on soft
mechanical diet after passing dysphagia
screen, and hooked to IVF. Vital signs,
neurologic vital signs, urine input and output,
and CBG were monitored.

• Laboratory workups were done.

– CBC 13.2; 36.4; 4.5; 13,300; N 85, L 10; plt
481,000
– NA 121 mmol/L
– K 3.4 mmol/L
– iCa 1.14 mmol/L
– Mg 1.9 mg/dL
• BUN: 13 mg/dL
• Crea: 0.69
• SGPT: 34
• CXR: no infiltrates or masses seen
• Urinalysis:
• 12 lead ECG: normal sinus rhythm
• ABG: 7.511, pCO2 34, pO2 59.9, hco3 27.2, O2
sat 93.1
• Blood CS: no growth x 2 sites
• Urine CS: no growth
• OP: 33 cm H20
• Xanthochromic, no pellicle
formation
• Glucose: 100 mg/dl (45-80
mg/dl or 60-70% of blood
glucose) (0.7)
• RBS: 219 mg/dL
• Protein: 3,833 mg/dl (45-55)
• TCC: 1,400
– RBC: 120
– WBC: 1,280
– N: 0%
– L: 100%
• CALAS: negative
• Bacterial Antigen (strep B,
Haemophilus In, strep
pneumo, E coli, Nisseria men)
: negative
• KOH: negative
• AFB smear: negative
• India ink: negative
• Gram stain: no
microorganisms
seen
• Culture: no growth
• TB PCR: negative
• Cell block and
cytology: no
malignant cells seen
• Viral panel: negative
(HSV, VZV, HCMV,
Dengue and JE)
DIAGNOSIS?
• Patient was started on Paracetamol,
Omeprazole, Anti-Kochs medications
(Rifampicin, Isoniaid, Pyrazinamide and
Ethambutol), Vitamin B Complex and KCl
syrup.

• Mannitol?

• On the 4th day of hospitalization, cranial CT

scan was done.
9/15/14
• Patient was also referred to neurosurgery.

9/19/14

Pt was more awake and

responsive, no headache,
decreased nuchal rigidity, no
focal weakness
• On day 7 postop,
patient was
noted to be
drowsy,
arousable to
vigorous
stimulation with
spontaneous
movements of
the extremities,
dysarthric, with
right central
palsy, RUE and
RLE noted to be 9/26/14
weaker than the
left. Patient
refused to name
objects.
• Na 126

• Serum osmolality: 266 mosm/kg (275-295)

• Random urine osmolality: 686 mosm/kg

(301-1093)

• Random urine sodium: 221 mmol/L (20-

110)

• Diagnosis? Complications?
• Started on hypertonic solution drip; mannitol was
discontinued.

• Started on aspirin, dexamethasone and

fludrocortisone.

• Na 126 – 131 – 143 – 150

• Motor strength was noted to be 4/5 on the RUE

and RLE, slurring of speech was also noted and
patient inconsistently followed commands.

• On Day 20, patient was referred to Rehab co-

management.
9/26/14
• Pt was discharged last October 20, 2014.

• She was fully awake, able to eat by herself

without dysphagia, minimal dysarthria, 4/5 on
the right side with minimal right central facial
palsy, able to stand and walk by herself for a
few minutes (10 minutes). She is no longer
disoriented, can name objects and now has
insight to her illness.