A 22 year old male, known case of hypothyroidism and bipolar disorder, alcoholic and smoker, known case of attention deficit hyperactive disorder, was admitted in our center with chief complaint of right sided weakness for 4 days, 2 episodes of seizure, vomiting and fever for 3 days. Initial labs are mentioned in table1.
On admission patient was afebrile, conscious and oriented with HR 76/min, BP 116/80 mmHg, SpO2 100 % on room air, RBS 146 mg/dl. On examination, the power in right upper limb was 4/5 and right lower limb was 1/5, pain and touch sensation decreased on right side, right side planter was equivocal, findings on the other side were within normal range.
NCCT brain was done which was suggestive of left parietal inflammatory granuloma. MRI brain showed left high frontal and parietal granulomatous etiology (? atypical tuberculosis, ? neurosarcoidosis, ? malignancy). CSF analysis was inconclusive.
The patient's family didn't give consent for intracranial biopsy and hence he was empirically started on ATT, meropenem and teicoplanin.
The patient was intubated on day 10 in view of fall in oxygen saturation and worsening sensorium. Repeat MRI brain was done which showed new onset involvement of brainstem and left cerebral hemisphere with increase in mass effect (Fig. 5). The family was recounselled and biopsy was taken after proper consent. Brain abscess and endotracheal tube culture showed the growth of Burkholderia pseudomallei.
The patient was then started on ceftazidime and cotrimoxazole. His clinical condition started to improve after 24 h and was extubated after three days. The patient was finally discharged in stable clinical condition after 28 days of hospital admission.