A 53 year-old man with no known medical history presents with a two-day history of worsening headache and confusion. He is brought in by his son. He hasn't had any recent travel. He doesn't take any medications. He takes protein powder with his kale shakes every morning. He hasn't had any recent infectious symptoms. Specifically, he hasn't had any respiratory nor gastrointestinal symptoms.
In the ED, he undergoes a non-contrast head CT, which is unrevealing. Vitals are notable for BP 120/68, HR 85, RR 12, SpO2 99%, T 38.3C. The ED consults you for help with determining the etiology and management for his acute encephalopathy.
On your exam, you find the patient to be somnolent, but briskly awakens to loud voice. He is alert and oriented to self only. He is able to follow simple commands. Pupils are equal and reactive. He has a right INO; ocular motility is otherwise intact. Face is symmetric. No dysarthria. No extremity weakness.
This is a 53 year-old patient with no known medical comorbidities who's had an acute onset of headache and encephalopathy (somnolence, confusion). Exam is notable for said encephalopathy as well as a right INO. This localizes to the pons/midbrain or subarachnoid space. Notably, he also has a fever. We must be consider an infectious etiology (i.e. acute bacterial meningoencephalitis, viral encephalitis), though a vascular etiology (i.e. ischemic stroke, aneurysmal subarachnoid hemorrhage, ruptured AVM) is also possible. The clinical history and time course is less suggestive of an alternative etiology such as autoimmune encephalitis. Malignancy is less likely with the time course given as well, but something like intratumoral hemorrhage could also be causative of the more acute presentation.
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