A 39-year-old male with a past medical history of alcohol abuse of several years' duration presented to the Emergency Department with chief complaint of headache. At the time of presentation he denied any chest pain, weakness, or other neurologic symptoms. Basic labs including complete blood count and basic metabolic panel were performed in the ED, which showed severe hyponatremia with a sodium of 116 mmol/L (normal 135-145 mmol/L) and serum osmolality of 235 mmol/L (normal 275-285 mmol/L). Further questioning of a family member revealed the patient was also experiencing mild confusion in the past few days. Physical exam showed the patient was oriented to person and place, while showing signs of chronic malnutrition. The rest of his serum chemistries, including complete blood count, were normal on presentation with the exception of hypochloremia (81 mmol/L). CT of the head on admission was obtained due to the patient's altered mental status, and it showed no edema or signs of infarct at the time. His chest X-ray performed in the ED showed nonspecific increased reticular markings. Kernig's and Brudzinski's signs were negative on physical exam. The patient had no pain or stiffness of the neck on admission. His vitals were otherwise stable, with normal temperature, O2 saturation, and respiratory rate on presentation. Alcohol level was negative in the ED, although he was kept on alcohol withdrawal protocol for the duration of his hospital stay due to the history of alcohol abuse and likelihood for withdrawal. The patient was admitted to a medical floor for hyponatremia and alcohol withdrawal workup. He did not receive any antibiotics in the ED as there was no indication of an infection at the time.
On the first day of admission, the patient was difficult to arouse in the morning after he spiked a fever of 101.5 F (38.6 C) overnight. Infectious Disease was consulted due to concern for meningitis due to altered mental status and fever. ID recommended starting the patient on Vancomycin, Zosyn, and Acyclovir, which the patient continued for the duration of his two-week hospital stay. A lumbar puncture was also performed the same day. The patient was transferred to the ICU due to concerns over airway protection due to rapidly worsening mental status. At this time a nine-panel drug screen was ordered which was negative. Lactic acid, procalcitonin, and blood cultures were all taken and were within normal limits. Nephrology was consulted for the hyponatremia, thought to be secondary to beer potomania and possible SIADH. In the ICU, the patient had a central line placed and he was started on 3% normal saline. Measurement of urine sodium was 191 mmol/L and urine osmolality was 626 mOsm/kg, although these labs were likely drawn after the administration of the hypertonic saline.
Initial results of the spinal tap showed a traumatic tap with 49 red blood cells/mm3, 8 white blood cells/mm3, glucose of 20 mg/dL, and protein of 188 mg/dL. Due to the low white blood cell count, ID felt meningitis was thought to be low on the differential. Acid fast culture was sent but would not return for several weeks from the health department. PCR for Mycobacterium tuberculosis was not available. A teleneurology consult was obtained due to the lack of an in-hospital neurology service, and they recommended treating the hyponatremia as a cause of the patient's encephalopathy. Due to the low white blood cell count in the cerebrospinal fluid, sterile blood cultures, and explanation of hyponatremia for the patient's altered mental status, antibiotics were discontinued on day #3 but eventually restarted as the patient's condition declined. He had a total of two weeks' course of antibiotics.
Over the next two days the patient's mental status continued to wax and wane, as did his low grade fevers. Additional infection workup was ordered, including RPR, GC/chlamydia, hepatitis, and HIV, all of which were negative. Repeat chest X-ray showed worsening of the reticulonodular opacities previously visualized on the chest X-ray performed in the ED. A cardiac ECHO was ordered which was limited due to the patient developing tachycardia but showed normal EF and no signs of vegetations or valvular dysfunction. A repeat CT of the head was ordered as the patient's mental status continued to decline (Figure 1). CT of the head showed new onset hydrocephalus, leading to a consult being placed with neurosurgery. Due to the new findings on CT scan an MRI was ordered, which showed subtle increased T2/flair signal interdigitating between the gyri, concerning for leptomeningitis (Figure 2). Neurosurgery placed an external ventricular drain catheter to drain the cerebrospinal fluid and relieve the hydrocephalus. There was no elevated intracranial pressure. The neurosurgeon did raise concern for meningitis based on the abnormal results of the original cerebrospinal fluid studies and the MRI; however treatment for TB was not started due to the negative cerebrospinal fluid samples.
Daily cerebrospinal fluid counts were sent to the lab from the ventriculostomy fluid collected. These repeat cerebrospinal fluid samples showed elevated white blood cell count, elevated red blood cell count, and low glucose with elevated protein. In total, three acid fast cultures were sent to the lab for analysis but their results would not come out for some time from the Health Dept. Patient was continued on Vancomycin, Acyclovir, and Cefepime. Culture results did not return until almost one month later.
Eight days into the patient's hospital stay and seven days into his ICU stay the patient experienced a cardiac arrest, likely due to increased pulmonary secretions and respiratory failure. He received ACLS with several rounds of epinephrine and suctioning and he eventually achieved return of spontaneous circulation. He was intubated for airway protection. A CT scan of the chest was ordered due to the persistently abnormal chest X-rays. CT of the chest showed diffuse airspace disease with associated reticular nodular opacities and apparent tree in bud configuration with small cavitary pulmonary nodule noted at the superolateral left lung apex (Figure 3). Bronchoalveolar lavage was performed by pulmonology to rule out infectious causes. Cultures were negative for fungus and grew out only normal respiratory flora. Either an acid fast culture was not sent from the bronchoalveolar washings or its results never came out at the Health Dept. Decision was made to transfer the patient to a local tertiary care hospital and the patient was accepted. However, no beds were available and the patient remained in critical condition in the ICU. A repeat MRI was performed which showed infarct of the left internal capsule and left putamen, as well as an acute small infarct in the right side of the pons. Neurosurgery continued to be concerned with infection including the possibility of TB. The ventricular drain shunt was discontinued as the intracranial pressure remained normal and the daily cerebrospinal fluid collection was stopped.
The patient began to experience worsening brain stem function during daily physical exams. QuantiFERON test was ordered and came back positive. This test was ordered due to the concern for extrapulmonary or meningeal TB from the prior chest CT which had showed a cavitary lesion. The patient was briefly started on four-drug RIPE therapy for only one day; however this was stopped as none of the acid fast cultures had yet returned positive. A cerebral perfusion test was ordered and was consistent with brain death. Family was contacted and present when the patient was extubated. He expired shortly after extubation.