Case-Based Modules > Case 4 > Stage 5

Sorry! There is clearly something very wrong with this patient neurologically (and also just systemically from a MICU perspective). Take a step back and think about this again: what has been happening to the patient? She's had some episodic fixed and dilated pupils in the setting of immunocompromise and septic shock. Neuroimaging and neurophysiology studies haven't shown anything specific, but her CSF studies raise concern for an atypical infection. Since there isn't anything large that's structurally causing the encephalopathy and pupillary findings, our most likely etiology with the clinical history and CSF studies is this atypical infection coating the cranial nerves. But what else could this process-- of leptomeningeal spread-- do from a physiologic standpoint to the brain that could also cause episodic signs/symptoms? Something about pressure maybe?

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