Contributed by Milon Amin, MD, Shveta Hooda, MD and Lydia Contis, MD
This 21 year-old male had a history of posterior urethral valves and subsequent obstructive uropathy, requiring a single renal transplantation in 1989. He developed chronic allograft nephropathy in 2001 and underwent a second renal transplantation in 2006, with subsequent multiple episodes of rejection. His treatment included Cellcept, Prograf, methylprednisolone, intravenous immunoglobulin and plasmapheresis. He presented to the emergency room complaining of severe headaches, nuchal rigidity, tachycardia and rigors.
Physical examination was significant for the presence of positive Brudzinski and Kernig signs. A CT scan of the head revealed no intracranial abnormalities.
A lumbar puncture was performed with the following results:
CEREBROSPINAL FLUID ANALYSIS
WHITE BLOOD CELL DIFFERENTIAL COUNT
CEREBROSPINAL FLUID SMEAR REVIEW
A Wright-stained cytospin smear of the cerebrospinal fluid (CSF) demonstrated mostly scattered neutrophils, along with fewer lymphocytes and monocytes. Several larger, circular forms, each containing a central dark core with a concentric clear area, were also identified (Images 1 and 2).