Match the lettered case histories with the numbered images 21-25.
An 89-year-old woman became progressively less active two weeks prior to her admission and was found unresponsive in bed on the day of admission. Her past medical history was unremarkable. On admission, she had a temperature of 39C, her neck was rigid and she had left facial droop. Head CT was normal. CSF was slightly cloudy with glucose 42 mg dl, protein 346 mg dl, and 345 white blood cells (4% polys, 95% lymphocytes). Gram stains and cytologic examination were negative. Treatment with ampicillin was started. The patient continued to be obtunded and chest x-rays, five days after admission, showed an infiltrate in the right lower lobe and pleural effusion. Bronchial aspirate was positive for Mycobacterium Tuberculosis. Treatment with antituberculosis medications was started. Over the ensuing 10 days, left hemiparesis and seizures developed, and the patient gradually lapsed into a coma. She became progressively dyspneic and hypothermic and died 23 days after admission.
An 18-year-old man who had just returned from the Mardi Gras celebration in New Orleans developed a sore throat, fever, headache, nausea and vomiting. He became confused, and two days after the onset of symptoms, his mother found him sitting up, drooling and staring straight ahead. He did not respond to her. En route to the hospital, he had a seizure. A CSF was clear with 200 WBC’s (93% polys), glucose 90 mg/dl and protein 91 mg/dl. Cultures were negative. He became agitated and unresponsive. Seizures continued. Brain MRI revealed hypodensity with enhancement in frontal and temporal lobes. A repeat spinal tap contained 350 cells, all lymphocytes. He was treated with Acyclovir and Decadron, but deteriorated further and died two weeks after admission.
A 35-year-old LPN was admitted to the hospital with fever, confusion and severe headache. CSF was xanthochromic with 1,051 WBC (98% neutrophils). Culture grew Neisseria Meningitidis. She was treated with antibiotics. She had seizures and confusion for one week. She was discharged 27 days after admission. Six days after discharge, she developed lethargy, seizures, and left hemiparesis. She died of a massive right hemispheric infarct.
A 31-year-old man with AIDS was admitted to the hospital for neurological evaluation. He had been on AZT for two years, but had been taking the medication erratically. Two months before admission, he developed hand tremors. Then he became progressively forgetful and weak. Left leg weakness and foot drop appeared three weeks before admission. His gait became ataxic, and his speech was slow and slurred. He was disoriented. There was no evidence of systemic infection. Brain MRI revealed mild bilateral diffuse white matter hypodensity. CSF showed 4 lymphocytes and normal protein and glucose. A brain biopsy was done.
A 26-year-old woman had weakness of the right leg, then of the left leg, and numbness of the hands and perioral area. She recovered without treatment but, three years later, she suddenly developed paraplegia, blindness and aphasia. She made a good recovery and was able to function for the next 9 years, except for slight residual weakness. Then, paraplegia recurred with spasms of the legs. She also suffered left facial paralysis and nystagmus. CSF showed 25 WBC’s, all lymphs, and normal protein and glucose. Tendon reflexes were brisk, and plantar responses were extensor. Subsequently she became incontinent. From that point on, her condition remained unchanged. She became demented, had frequent urinary tract infections and died of pneumonia at age 47.
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