Dr. Howard M. Heller: The 24-year-old presented with a 3-week history of pain and headache and dyspeptic progression of gastrointestinal symptoms. Four days before admission, he received a diagnosis of Kovid-19. He did not have fever, and the results of the physical examination were consistent with an indication of meningial inflammation. He had very minor complete lymphopenia and mild anemia. Lumbar puncture was notable for an elevated opening pressure, and CSF analysis showed lymphocytic pleocytosis, slightly lower glucose levels, and a normal protein level.
There are many epidemiological, clinical, and laboratory clues in this case. We need to find out which of these may be the “red herd”, or unrelated to the diagnosis, and to avoid being anchored and misled by other clues.
Can Kovid-19 be credited for this patient’s illness? During the Kovid-19 epidemic, this diagnosis has certainly been on the minds of physicians and patients. The oxygen saturation of this patient was normal when he was breathing ambient air, and a chest radiograph showed no opacity. If he has a decrease in oxygen saturation with activity and diffuse ground-glass opacities on chest radiography, a chest CT would be appropriate, as it is a sensitive method for the diagnosis of Kovid-19 pneumonia.
Kovid-19 is associated with a hypercoagulable state that can cause pulmonary emboli, but this patient was a normal D-dimer level, a finding that reduces the likelihood of pulmonary emboli. In addition, covid-19 has been associated with encephalitis, but covid-19 encephalitis usually occurs in the presence of severe pulmonary disease and is usually associated with evidence of stroke on frontotemporal hypoperfusion, leiomeningeal enhancement, or MRI.1,2 Venous sinus thrombosis may occur in patients with COSID-19, but there is no evidence of venous sinus thrombosis on MRI in this patient. I think Kovid-19 is a coincident diagnosis in this case and not the most likely cause of neurologic disease.
Whenever we hear the term “landscape” or “hiking in New England”, we anchor on tickling diseases, especially in spring. As a landslide, the patient was not able to work from home during the bandh for the Kovid-19 pandemic. When headache is the predominant symptom, we should be concerned about cerebral vasculitis and Rocky Mountain spotted fever. However, in the absence of 3 weeks in fever and disease, this diagnosis is unlikely.
The patient did not have leukopenia, thrombocytopenia, or elevated aminotransferase levels, so anaplasmosis is not a major diagnostic consideration. They had mild anemia but normal aspartate aminotransferase and lactate dehydrogenase levels; These findings distance us from an infection that causes hemolysis, such as babysiosis. Furthermore, neither anaplasmosis nor babiosis would be the cause of central nervous system (CNS) findings in this patient.
Borrelia Miamoto Sometimes severe, sometimes spreading, febrile illness and lymphocytic meningitis can be caused. Powassan virus can cause encephalitis and meningitis, but these manifestations usually involve the temporal lobe rather than the basal ganglia. There were no reported cases of infection with the Pawson virus or any arbovirus in Massachusetts during the first 6 months of 2020, when the patient was diagnosed with the disease.
Early proliferation can cause lyme borreliosis lymphocytic meningitis, and increased intracranial pressure has been described with pseudotumor cerebri, but these manifestations are more common in children than in adults.3 Lyme encephalitis can lead to a variety of MRI findings but not the abnormalities described in this case.4,5 Another occupational hazard for landslides is sporotrichosis, which can cause lymphocytic meningitis, but this patient did not have skin lesions that were commonly associated with this infection.6
Although this patient’s sexual history does not specifically indicate sexually transmitted infections, we need to consider this possibility, as some patients are initially reluctant to share details of their sexual history. Sexually transmitted infections that can cause lymphocytic meningitis include acute human immunodeficiency virus (HIV) infection, syphilis, and herpes simplex virus type 2 infections. There were no relevant findings on the examination of the patient, such as oral or genital lesions or erythematous rash.
Given that this patient had recently immigrated to the United States, we need to consider a possible diagnosis involving Central America. Tuberculosis can cause meningitis with menonucleosis, but with this infection, CSF protein levels are much higher than the levels typically seen in this patient. In addition, he had no calcified granulomata on chest imaging; On brain imaging, we would be likely to see symptoms of meningitis or tuberculosis, but not cystic-looking lesions located in the basal ganglia. Cystercarcosis usually exacerbates many, scattered cysts surrounded by edema in patients with active disease or calcification of chronic ulcers. Toxoplasmosis often involves the basal ganglia, but usually ring-enhancing lesions in immunologic patients with edema. Chagas disease can cause meningoencephalitis and focal lesions during reactivation of infection in immunocompromised patients. Paracoccidioidomycosis is endemic in Central America, but neurological involvement is uncommon and ring-enhancing lesions are commonly seen. Coccidioidomycosis usually causes meningitis, even among immunologists, and although it is not endemic in Central America, we are not told how the patient traveled from Central America to Massachusetts; Many expatriates go through a difficult journey through the Sonoran Desert in northwestern Mexico. Both histoplasmosis and cryptocurrency can cause lymphocytic meningitis and are possible diagnoses in this case.7 Finally, because the patient did not have fever and his inflammatory markers were not uncommonly abnormal, we need to consider non-infectious causes, specifically CNS lymphoma.
The condition that is usually associated with a cystic, grapilic appearance in the brain, especially in the basal ganglia, and usually causes a very high intracranial pressure is cryptocurrency.8 Cryptococcal meningitis can occur in seemingly healthy people, but it usually occurs in people who are much older than this patient; It usually occurs in immunocompromised patients, especially in the presence of advanced HIV infection. This patient had no identifiable risk for HIV infection or relevant findings on examination such as thrush or lymphadenopathy. Hypergammaglobulinemia is a hallmark of humorous pathology associated with HIV infection, particularly at the late stage, but this patient’s globulin level and albumin: globulin ratio were normal.9 Furthermore, their history was not suggestive of hypogammaglobulinemia or any other underlying immunodeficiency. Given that this patient’s presentation is most consistent with cryptococcal meningitis, I suspect that he also has a new diagnosis of advanced HIV infection. To establish these diagnoses, I will perform a CSF test for cryptococcal antigens and a fungal wet preparation. If a cryptococcal disease is identified, the patient must undergo evaluation for an underlying immunodeficiency, including an HIV test. If HIV testing is negative, the characterization of T-cell subsets by flow cytometry should be performed to rule out idiopathic CD4 + lymphocytopenia.
Herbert Needleman, MD, a physician-scientist whose lead in consumer products was removed due to research…
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