MEDizzy - A 39-year-old man presents with a headache and altered

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Central Nervous System (I)

A 39-year-old man presents with a headache and altered mental status of 60 hours’ duration. On examination, he is afebrile and normotensive and has a reduced level of consciousness with aphasia. Lumbar puncture is performed and the CSF obtained has a lymphocytic pleocytosis with modest protein elevation. An MRI of the brain shows focal hyperintense cortical lesions. A stereotaxic brain biopsy shows chronic inflammation with granulomas involving arterioles and venules. Which of the following therapeutic options is most appropriate for this man?

ExplanationPrimary angiitis of the CNS is uncommon. It involves small peripheral vessels. The cause is unknown, but it appears to be immunologically mediated, so immunosuppressive therapy is of benefit, such as cyclophosphamide and methylprednisolone. Infections are unlikely to produce such focal involvement of small vessels. Hypertensive encephalopathy produces fibrinoid necrosis of arterioles. NSAIDs or aspirin as anti-inflammatory or anti-pyretic agents are not strong enough to address the inflammatory process in this case.