Case 113 -- Dizziness and Headache

Contributed by Jianzhou Wang, MD., Ph.D. and A. William Pasculle, Sc.D.
Published on line in July 1997


The patient is a 58-year-old, white female with history of noninsulin-dependent diabetes, who was transferred to UPMC for evaluation of altered mental status. The patient reportedly had a "cold" one week before admission and had been feeling sick for three days with diarrhea, dizziness, and headache. The patient was found acutely disoriented and confused by her family member the morning of admission. There is no history of recent trauma, and no known toxic substance exposure. CT scan of head at outside hospital showed a questionable right temporal lobe lesion. Examination revealed a disoriented and confused female, the rest of physical examination and neurological evaluation were unremarkable. Laboratory studies showed blood glucose of 368, WBC of 23,800 with 90% PMN's, 4% lymph's, 4% mono's, and 2% bands. The patient was given antibiotics empirically to treat possible meningitis. She underwent lumbar puncture, which revealed a cloudy purulent cerebral fluid. Examination of CSF showed WBC of 20,800 with 96% of PMN and 4% monocytes . Gram stain of CSF was negative for microorganisms. A CT scan was repeated, which showed intense ependymal enhancement within the lateral ventricles, and scattered, rounded hypodensities with mild ring enhancement (Image 01). At the same time, CT-guided stereotactic brain biopsy and aspriation of the lesion was performed. Gram stain of brain biopsy showed scattered gram positive cocci in short chains in a necrotic background (Image 02). The patient was treated with multiple intravenous and intrathecal antibiotics. The patient developed seizure and respiratory failure, and died one week after admission.



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