Photo taken form www.thereddragonhood.com/ 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
CXR - N
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 ?
9 comments:
Hmm,let me try OK!
Dx:SYRINGOMYELIA.
ok,since syringomyelia is not correct,i have another diagnosis.
WEST NILE MENINGITIS.
Nope, both incorrect. Second one closer though.
Nope, both incorrect. Second one closer though.
Ok,! I will give another try :)
Dx: West Nile Fever[ENCEPHALITIS}
HoPeFuLLy It'S cOrReCt ThIs TiMe!
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.
Yes, it is tularaemic meningitis. Typhoidal type. Well done.
hi,
i learned something new:)
waiting 4 ur next post!
nile west encephalitis
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