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Washington University Experience | MYELIN (IMMUNE-MEDIATED) | AHL | AHL | 8A0 Case 8 History
Case 8 History ---- The patient was a 58 year old woman with mild hypertension and obesity. She developed right calf pain on December 23 and low back discomfort and, 3 days later, she had flu-like symptoms including bifrontal headache, sinus pressure, chills and fever (107oF) that responded to Advil. Of note, one of her sons, who was institutionalized due to cerebral palsy, had recently come home for the holidays and had a similar illness. Shortly thereafter she developed right foot tingling and right leg weakness for which she was seen in the Emergency Room of a local hospital. Her white count was 16,800 and her erythrocyte sedimentation rate was 72. She was thought to have sinusitis and was discharged on levofloxacin. On December 29th, she was admitted due to worsening symptoms. Her neurological exam at the time revealed sharp discs, supple neck, foot paresthesias bilaterally, brisk leg reflexes with up-going toes bilaterally. Strength, sensation and gait were intact. Head CT was unremarkable. On December 30 she was transferred to MGH due to progressive weakness, dysarthria and shortness of breath. On examination her mental status was intact with mild dysarthria. Her right pupil was 4mm non-reactive, left pupil 2 mm reactive, and bilateral VI nerve palsies; bilateral ptosis and facial weakness were present. Motor exam showed weakness in upper and lower extremities and decreased rectal tone. Her sensory exam showed diminished light touch and temperature sensation throughout. There was areflexia in the lower extremities with up-going toes. Lumbar puncture showed protein of 247, glucose of 45, 350 white blood cells (60% neutrophils, 40% lymphocytes) and no micro-organisms. Urine toxicology screen was negative. Empiric antibiotic coverage for presumed meningitis was started. Unfortunately, the patient became hypotensive, bradycardic and was pronounced dead on January 4th, 14 days following her initial presentation.
Necropsy findings: At autopsy the brain was externally normal and weighed 1335 grams. The remainder of the autopsy was non-contributory.
Special stains for infectious agents were negative, including Gomori methenamine silver for fungi, PAS stain, Gram stain, and Steiner stain. Immunocytochemistry was negative for varicella-zoster virus 01ZV), herpes simplex virus, and Toxoplasma gondii. Immunofluorescence studies performed at the CDC were negative for rabies virus and Acanthamoeba.
