Esperti Shawn, Stoelting Austen, Mangano Andrew, Patel Dveet, Sansbury Jilian, Sherertz Robert
Department of Internal Medicine, Grand Strand Health, Myrtle Beach, SC, USA.
Case Rep Infect Dis. 2020 Jul 13;2020:8232178. doi: 10.1155/2020/8232178. eCollection 2020.
A 70-year-old immunocompetent male in South Carolina was admitted secondary to altered mental status and headache without focal neurological deficits. Head CT was negative. Lumbar puncture (LP) revealed normal glucose, elevated protein, and lymphocytosis. Opening pressure was 15 cm of H20. CSF lateral flow assay was negative for cryptococcal antigen; CSF cultures showed no growth. The patient rapidly improved on acyclovir and was diagnosed with presumed viral meningitis, as viral PCR and fungal culture were pending at time of discharge. The patient's condition quickly worsened and the patient returned one day later with right arm weakness and dysarthria. Brain MRI revealed T2/flair signal abnormalities in the left frontal lobe with associated parenchymal enhancement. Repeat LP revealed increasing white blood cell count with a worsening lymphocytosis and decreasing glucose, and opening pressure remained normal. CSF fungal culture from the first admission grew , and repeated CSF cryptococcal antigen and culture returned positive. The patient was started on IV steroids, induction Amphotericin and Fluconazole, followed by maintenance oral Fluconazole. The patient's clinical course was complicated by a brainstem lacunar infarction, which led to demise. We present this case of meningoencephalitis to highlight the risk factors, characteristics, and challenges in diagnosis and treatment of an emerging disease in the Southeastern United States.
南卡罗来纳州一名70岁免疫功能正常的男性因精神状态改变和头痛入院，无局灶性神经功能缺损。头部CT检查结果为阴性。腰椎穿刺（LP）显示葡萄糖正常、蛋白质升高和淋巴细胞增多。初压为15cm水柱。脑脊液侧流试验隐球菌抗原阴性；脑脊液培养无生长。患者使用阿昔洛韦后迅速好转，诊断为疑似病毒性脑膜炎，因为出院时病毒PCR和真菌培养结果尚未得出。患者病情迅速恶化，一天后因右臂无力和构音障碍再次就诊。脑部MRI显示左额叶T2/FLAIR信号异常并伴有实质强化。再次腰椎穿刺显示白细胞计数增加，淋巴细胞增多加重，葡萄糖降低，初压仍正常。首次入院时的脑脊液真菌培养生长出[具体真菌名称未给出]，重复脑脊液隐球菌抗原检测和培养均呈阳性。患者开始接受静脉注射类固醇、两性霉素诱导治疗和氟康唑治疗，随后口服氟康唑维持治疗。患者的临床病程因脑干腔隙性梗死而复杂化，最终导致死亡。我们报告这例脑膜脑炎病例，以强调美国东南部一种新发疾病在诊断和治疗方面的危险因素、特征及挑战。
