Sunday, May 10, 2009


Photo taken form images/rabbit.jpg

Text adapted from Archieves of Neurology (April 2009)

A 21 years old previously healthy man presented with 7 days cough with black and yellowish sputum, fever, chills, myalgia and pleuritic chest pain. 3 days before admission, had progressive worsening headache with neck stiffness and 8 episodes of watery diarrhoea

He had taken amoxycillin for 1 day

He had recently changed job, working as a professional landscaper 7 days before onset of symptoms

He had performed lawn mowing and leaf blowing services and noted he had dead rabbits in the areas he worked

T - 39.6 C, Alert, orientated to time, place, person

Stiff neck, no weakness or numbness

Lungs - bibasal crepts with exp ronchi

No lymphadenopathy,  skin lesions, ulcerations

CT brain - Normal

WBC - 10.4 (78% N) ESR - 40 mm/h

CSF - Cell count 1416/mm3, 19% N 73% L RBC 23, glu 41 mg/dl(glu 123 mg/dl), pro 2660 g/dl

Gm stain CSF -ve


MRI - cerebellar tonsillar herniation consistent with Chiary Type 1 malformation without evidence of brainstem syrinx

Treated with IV Ceftrixone and IV Vancomycin

Day 4 , headache worse and developed diplopia and nausea

Repeated LP -Opening pressure - 49 cmH2O, total nucleated cell count 2590/mm3 32% N 43%L 25% M, glu 28 mg/dL, pro 2950 g/dL (RBS - 128 mg/dL) 

Gram stain negative

What is the diagnosis ?


Vimala said...

Hmm,let me try OK!

Vimala said...

ok,since syringomyelia is not correct,i have another diagnosis.


Wuchereria said...

Nope, both incorrect. Second one closer though.

Wuchereria said...

Nope, both incorrect. Second one closer though.

Vimala said...

Ok,! I will give another try :)

Dx: West Nile Fever[ENCEPHALITIS}

HoPeFuLLy It'S cOrReCt ThIs TiMe!

cheeweishen said...

From the WBC with leukocytosis with predominant neutrophilia- it is suggestive of bacterial infection.

From the CSF, there’s intracranial hypotension, lymphocytic pleocytosis, increased protein level and decreased glucose level which doesn’t respond to antibiotics given( Amoxicilln, Ceftriaxone and vancomycin). it is suggestive for bacterial meningitis except for the lymphocytic pleocytosis which mayb present in 10% of the cases of bact meninigitis. So in this case due to intracellular microbes?

As the Gram staining revealing gram negative meningitis plus the picture of rabbit shown above- Tularemic meninigitis? Pneumonic form? With fever, chill, cough, pleuritic chest pain and bibasal crepitation with expiratory rhonchi.

I would check the titre and maybe add tetracycline in treatment.

Wuchereria said...

Yes, it is tularaemic meningitis. Typhoidal type. Well done.

vimala said...

i learned something new:)
waiting 4 ur next post!

Anonymous said...

nile west encephalitis