Case study #5
A 37-year-old woman was brought in by paramedics after suffering a seizure at her home. Per her husband, she was feeling ill and confused for the past couple of days, complaining of fever and headaches. He also states that she has been particularly irritable and has been slurring her speech since yesterday. She has otherwise been in good health and only relates a history of an oral blister a week ago. He denies any remote travel history. Her temperature is 40°C (104°F), blood pressure is 150/78 mm Hg, pulse is 98/min, and respiratory rate is 20/ min. She is confused and disoriented, but the rest of the neurologic examination is unremarkable. There is no associated papilledema on funduscopy. Kernig’s and Brudzinski’s signs are negative. CT of the head is normal. A lumbar puncture is performed and cerebrospinal fluid analysis shows: Protein: 82 mg/dL Glucose: 63 mg/dL WBC count: 150/mm³ Gram stain: negative Which of the following is the most likely diagnosis? (A) Bacterial meningitis (B) Herpes simplex virus encephalitis (C) Neurocysticercosis (D) Rabies encephalitis (E) Subacute HIV encephalomyelitis (F) Tabes dorsalis
So, here we are... The correct answer is B! The patient is exhibiting signs of HSV encephalitis. The clinical syndrome is characterized by fever, headache, seizures, focal neurologic signs, and impaired consciousness. It is the most common cause of fatal sporadic encephalitis in the United States, mostly occurring in children and adolescents. Central nervous system invasion occurs via the trigeminal nerve following an episode of primary HSV-1 of the oropharynx. CSF analysis typically shows lymphocytic pleocytosis, increased erythrocytes, elevated protein, and normal glucose. The patient’s history of a recent oral ulcer favors HSV as the etiology of this patient’s encephalitis. Answer A is incorrect. Bacterial meningitis presents with a classic triad of fever, nuchal rigidity, and change in mental status, including skin lesions consisting of petechiae and purpura. CSF analysis reveals pleocytosis, elevated protein, and decreased glucose. Answer C is incorrect. Neurocysticercosis is caused by the larval stage of Taenia solium, the pork tapeworm. The majority of neurocysticercal infections are asymptomatic. CSF analysis typically shows mild pleocytosis, with normal protein and glucose levels. Answer D is incorrect. Rabies encephalitis is an unlikely diagnosis in the absence of a history of a dog or bat bite. Most patients present with hydrophobia, aerophobia, pharyngeal spasms, and hyperactivity. Cerebrospinal fluid shows pleocytosis, normal glucose, and a mildly elevated protein. Answer E is incorrect. The patient’s history was not suggestive of active HIV disease and thus makes subacute HIV encephalomyelitis unlikely. Answer F is incorrect. Tabes dorsalis presents with paresthesias, abnormal gait, and shooting pains of the extremities or trunk. Physical findings also include diminished peripheral ref l exes and altered position and vibration sense, as well as Argyll Robertson pupils. CSF is often normal. Congratulations to everyone!
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