Case-Based Modules > Case 4 > Stage 4

The patient gets an LP. Initial studies are notable for WBC 250 (60% lymphocytes), RBC 10, protein 180, glucose 50. The remainder of the CSF studies are pending. They didn't manage to record an opening pressure. In the meanwhile, you review the EEG and see the updated report.

cEEG Findings (Days 2-3):

  • Abnormal in wakefulness and sleep
  • Diffusely slow, disorganized background
  • No sleep architecture
  • Abundant delta slowing that was at times rhythmic (GRDA), with frequency 0.5-1Hz
  • No epileptiform abnormalities
  • No clinical events captured

You tell the MICU you'll follow along peripherally, but to call you back if anything changes. By day 4 of admission, she regains pupillary reactivity, and she begins attending to examiners in the room.

Unfortunately, on day 5 of admission, she again becomes non-reactive to vocal and noxious stimuli, and her pupils are again fixed and dilated. You're paged to urgently evaluate the patient.

What do you make of the CSF studies?

Abnormal, for sure. Not a florid pleocytosis (in the 1000s range), but they're immunosuppressed, so who knows. The pattern of mild-moderate lymphocyte-predominant pleocytosis with elevated protein and somewhat lower glucose is very concerning for fungal infection moreso than bacterial. For this patient, something like Cryptococcus definitely rises up in the differential diagnosis. A result on that CrAg would be very helpful now. Would this explain the original reason for consultation-- the fixed and dilated pupils with depressed mental status?


What's happening? What do you do now?

Shoot. The same thing happened again! Except we have more data from tests, and we still don't have a unifying answer. Or do we?

Of course, you go to examine the patient. Same poor exam as you had seen on that first day on which you were consulted. You suggest a STAT non-contrast head CT.

> Click here to continue


Go back

Suggested Reading: