Match the lettered case histories to the numbered images 16-20.
An 80-year-old man was admitted to the hospital unresponsive and febrile. Several years earlier, he had been diagnosed as having an “organic brain syndrome” and he had also sustained a subdural hematoma. The past several days, family members noted that he was becoming increasingly lethargic and did not eat or drink. On admission, the patient had purulent material in the pharynx. His neck was stiff. There was a pleural rub on the left. Brain MRI showed mild dilatation of the ventricles. A CSF was cloudy with 300 WBC (96% polys, 4% lymphocytes). Protein was 1080 mg/dl and glucose was 2 mg/dl. Gram stains revealed gram-positive diplococci. Blood cultures grew pneumococcus. Treatment with ampicillin and gentamicin was started. The patient remained unresponsive and had a cardiorespiratory arrest one day after admission.
A 56-year-old woman was admitted to the hospital with fever, aching, dizziness and disorientation. She was an insulin dependent diabetic and had a history of hypertension. One month earlier, she had the left adrenal gland removed for an adenoma that had caused Cushing’s syndrome. She was receiving replacement corticosteroids. Mental status deteriorated and she became comatose and had intractable seizures. CSF, on admission, had 17 cells, all lymphocytes, protein 53 mg/dl and glucose 77 mg/dl. CSF cultures were negative. Urine cultures grew Candida albicans. Blood cultures were negative. Initially, brain MRI was normal. Later, it revealed diffuse encephalomalacia.
29-year-old truck driver was investigated for persistent malaise, cough and diarrhea. Chest x-rays revealed pneumonia with pleural effusion. Fiberoptic bronchoscopy with lung biopsy revealed pneumocystis. He
also had diarrhea due to cryptosporidiosis. Helper T-cells were diminished to undetectable levels. He was discharged on Bactrim, Flagyl and antibiotics. Six weeks later, he developed headache, obtundation and seizures. CSF had 11 WBC’s, all lymphocytes, protein 137 mg/dl and glucose 26 mg/dl. Cryptococcal antigen was positive.
A 9-year-old boy with severe combined immunodeficiency was admitted because of productive cough and dyspnea. He had had a variety of infections, starting shortly after birth, and had developed multiorgan dysfunction. He had chorioretinitis when he was 5 years old and was blind. Concurrent with the recent onset of cough, he had become lethargic and did not seem to recognize his Braille letters. While in the hospital, he developed fever, pneumonitis, cellulitis of the left foot, and had episodes of stiffening (?seizures), aspiration and hypotension. He gradually became comatose and died 15 days after admission. A brother had died at 2 ½ years of age from complications of SCID.
A newborn girl, who was born at 36 weeks, did well at home for 12 days and then developed fever (38.6 C), lethargy, and seizures. She was admitted to the hospital and was treated with phenobarbital with good seizure control. Fever and lethargy continued and, a head CT, 7 days after admission, revealed diffuse hypodensity. Two days later, her sutures split. CSF was xanthochromic with 36,000 RBCs, 199 WBCs (98% lymphocytes), protein 1330, and glucose 16. She became comatose and died 4 days later.
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