Case-Based Modules > Case 4 > Stage 5

Sorry! Getting a little closer. You're now thinking more along the lines of what could this presumed infection be doing to affect her pupils and mentation. Steroids are not totally unreasonable (no one gets to die in the ICU without getting empiric steroids, after all). However, there wasn't any evidence of edema on her MRI. Try to think of what else this infection could be doing. 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 raised 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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