Thursday, March 31, 2016

Refresher II

I'm not sure if this counts as a refresher type case, but it's an important one nonetheless.

The top two panels of the MRI were taken two days after admission. The lower two panels were taken two weeks after admission.

This patient presents with acute onset focal neurologic deficits. He is altered with hemiparesis, dysphagia, aphasia, ataxia, and seizures. He also has been running a high fever.

Challenge: When you perform the lumbar puncture, what diagnostic test should you order?

Image shown under Fair Use.


Craig Chen said...

Refresher II

This is HSV encephalitis. A PCR for HSV should be sent on the CSF. Empiric IV acyclovir should be given.

Source: UpToDate.

RaH said...

i was thinking about a bacterial meningitis, but there was no neck stiffness. What points you towards a viral encephalitis if you have no MRI handy?

Craig Chen said...

great comment - i think bacterial meningitis is definitely on the differential - the temporal enhancement on the MRI is what tips this towards HSV encephalitis. Practically, I think you would cover for both bacterial and viral etiologies until the CSF comes back