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 ?
The time we feared most and the time we can't wait for it to be over. However, we choose to face it. PACES exam.....
