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Acute encephalitis with abnormal liver function tests: question
Journal of Clinical Neuroscience 23 (2016) 128
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images in Neuroscience: Question
Acute encephalitis with abnormal liver function tests: question A. Merwick a,b,⇑, P. Cowley a, G. Ingle a a b
National Hospital for Neurology and Neurosurgery, Box 92, Queen Square, London WCIN 3BG, UK Chelsea and Westminster Hospital National Health Service Foundation Trust, London, UK
1. Case description A 19-year-old woman presented with headache and ataxia after returning from a holiday on the Spanish island of Majorca. She kept pet cats at her home in the United Kingdom. She had a prodromal rash over her forehead, with facial swelling. She developed vomiting, agitation, slurred speech and became febrile. On initial examination, she was drowsy with a Glasgow coma scale score of 10/15 (E3V2M5). Her limb examination showed increased tone on the left, with pyramidal weakness and brisk reflexes. Her cerebrospinal fluid (CSF) showed 1 white blood cell/cm3, 2 red blood cells/cm3, CSF glucose 6.0 mmol/L, serum glucose 7.2 mmol/L (normal range: 3.9–5.8), and CSF protein 0.42 g/L (normal range: 0.13–0.45). A gram stain, culture and viral polymerase chain reaction were negative, and oligoclonal bands were positive in both the CSF and serum. She had a serum neutrophilia with a total white cell count of 11.5 109/L (normal range: 3–10.0) and elevated liver transaminases, with alanine aminotransferase at 693 international units (IU)/L (normal range: 10–35) and alkaline phosphatase 111 IU/L (normal range: 35–104). A brain MRI showed abnormal signal in the pons and right thalamus, left external capsule, rostrum of the corpus callosum, left insula and anterior temporal lobe, and superior parietal lobe bilaterally (Fig. 1). The right superior frontal gyrus juxtacortical white matter was also involved, with areas of restricted diffusion in the left insular white matter and rostral corpus callosum. 2. The most likely diagnosis is: A. Bartonella infection B. Fungal infective endocarditis C. Leptospirosis D. Multiple sclerosis E. Viral encephalitis Answer on page 169.
DOI of answer: http://dx.doi.org/10.1016/j.jocn.2015.06.012
⇑ Corresponding author. Tel.: +44 845 1555000.
E-mail address: [email protected] (A. Merwick). http://dx.doi.org/10.1016/j.jocn.2015.04.015 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Fig. 1. (A, B, C, D) Axial T2-weighted MRI: (A) high signal abnormality throughout the pons, (B) high signal in the left external capsule, (C) further areas of signal abnormality in the right thalamus, (D) high signal in the rostrum of the corpus callosum and superior parietal lobe white matter. (E, F, G, H) Axial diffusion weighted MRI: (E) pontine high signal, (F, G) high signal in keeping with multiple areas of acute restricted diffusion in the left insula white matter, rostral corpus callosum, (H) restricted diffusion in the right centrum semi-ovale and splenium of the corpus callosum. (I, J, K, L) Axial apparent diffusion coefficient (ADC) imaging: (I) increased signal in the pons, (J, K) reduced signal on the ADC in the left insula and rostral corpus callosum, (L) reduced ADC in the splenium of the corpus callosum.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images in Neuroscience: Question
Acute encephalitis with abnormal liver function tests: question A. Merwick a,b,⇑, P. Cowley a, G. Ingle a a b
National Hospital for Neurology and Neurosurgery, Box 92, Queen Square, London WCIN 3BG, UK Chelsea and Westminster Hospital National Health Service Foundation Trust, London, UK
1. Case description A 19-year-old woman presented with headache and ataxia after returning from a holiday on the Spanish island of Majorca. She kept pet cats at her home in the United Kingdom. She had a prodromal rash over her forehead, with facial swelling. She developed vomiting, agitation, slurred speech and became febrile. On initial examination, she was drowsy with a Glasgow coma scale score of 10/15 (E3V2M5). Her limb examination showed increased tone on the left, with pyramidal weakness and brisk reflexes. Her cerebrospinal fluid (CSF) showed 1 white blood cell/cm3, 2 red blood cells/cm3, CSF glucose 6.0 mmol/L, serum glucose 7.2 mmol/L (normal range: 3.9–5.8), and CSF protein 0.42 g/L (normal range: 0.13–0.45). A gram stain, culture and viral polymerase chain reaction were negative, and oligoclonal bands were positive in both the CSF and serum. She had a serum neutrophilia with a total white cell count of 11.5 109/L (normal range: 3–10.0) and elevated liver transaminases, with alanine aminotransferase at 693 international units (IU)/L (normal range: 10–35) and alkaline phosphatase 111 IU/L (normal range: 35–104). A brain MRI showed abnormal signal in the pons and right thalamus, left external capsule, rostrum of the corpus callosum, left insula and anterior temporal lobe, and superior parietal lobe bilaterally (Fig. 1). The right superior frontal gyrus juxtacortical white matter was also involved, with areas of restricted diffusion in the left insular white matter and rostral corpus callosum. 2. The most likely diagnosis is: A. Bartonella infection B. Fungal infective endocarditis C. Leptospirosis D. Multiple sclerosis E. Viral encephalitis Answer on page 169.
DOI of answer: http://dx.doi.org/10.1016/j.jocn.2015.06.012
⇑ Corresponding author. Tel.: +44 845 1555000.
E-mail address: [email protected] (A. Merwick). http://dx.doi.org/10.1016/j.jocn.2015.04.015 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Fig. 1. (A, B, C, D) Axial T2-weighted MRI: (A) high signal abnormality throughout the pons, (B) high signal in the left external capsule, (C) further areas of signal abnormality in the right thalamus, (D) high signal in the rostrum of the corpus callosum and superior parietal lobe white matter. (E, F, G, H) Axial diffusion weighted MRI: (E) pontine high signal, (F, G) high signal in keeping with multiple areas of acute restricted diffusion in the left insula white matter, rostral corpus callosum, (H) restricted diffusion in the right centrum semi-ovale and splenium of the corpus callosum. (I, J, K, L) Axial apparent diffusion coefficient (ADC) imaging: (I) increased signal in the pons, (J, K) reduced signal on the ADC in the left insula and rostral corpus callosum, (L) reduced ADC in the splenium of the corpus callosum.