PathWays Case Study: March 15
A 69-year-old man from Minnesota was admitted to the hospital due to mental status changes and intermittent fevers. The patient immigrated to the United States from Southeast Asia approximately 30 years ago. About one month prior to admission, the patient experienced a short period of fevers and shortness of breath. This was managed by his local physician as a possible case of influenza.
Two weeks later, he developed sudden-onset, left-sided weakness and drooping of his face. He was diagnosed with an ischemic stroke and was treated accordingly in a local hospital.
During the hospitalization, he developed worsening somnolence and intermittent fevers (maximum temperature 38.9°C). Hospital-acquired pneumonia was suspected and he was treated with a course of antibacterial agents with no improvement. Physical examination revealed that the patient was somnolent, but arousable, with a left-sided hemiparesis, no nuchal rigidity, and both Kernig's and Brudzinski's signs were negative. Since the presumed diagnosis of stroke was not enough to explain his somnolence and fevers, an infectious etiology was pursued.
Blood cultures were collected and demonstrated no growth after 5 days. Serologic testing was negative for HIV and hepatitis A/B/C. A lumbar puncture was performed and the CSF was negative for microorganisms on a Gram stain, a fungal smear, and an acid-fast smear. Chemical and microscopic studies of the CSF showed 49 total nucleated cells with 64% of neutrophils, 28% monocytes, and glucose less than 20% with a protein level of 219 mg/dL (reference range, 0-35 mg/dL).
Fang Zhao, M.D., Ph.D.
Resident, Clinical Pathology
Nancy Wengenack, Ph.D.
Consultant, Division of Clinical Microbiology
Professor of Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine