St. Paul's Morning Report

Today we explore the case of a healthy man whose symptoms of headache and dyspnea at first glance seem to be obviously explained, until things don’t go quite as expected. Stay tuned as we explore the causes for our patients presentation and how that changes as the clinical course progresses. 

Initial Exam

• BP 119/56, HR 93, RR 20, 92% O₂ sat on room air, Temp 38.1 ℃
• Alert and oriented, appears uncomfortable
• Skin – Blanching, macular, non-pruritic, erythematous rash on posterior ankles, dorsum of left foot, and abdomen. No stigmata of endocarditis
• Respiratory – Bibasilar crackles on inspiration
• Cardiac and GI – unremarkable
• Head and neck – slight nuchal rigidity, no cervical lymphadenopathy
• Neurologic – 4+ bilateral patellar reflexes with clonus, slight tremor, negative Brudzinski and Kernig signs, otherwise unremarkable

Initial Investigations

• Blood
  • WBC 16.3 x 10⁹/L (normal 3.5 – 10.5 x 10⁹/L), neutrophil count 12.3 x 10⁹/L (normal 2.0 – 7.5 x 10⁹/L)
  • Hgb 129 g/L (normal 125 – 170 g/L)
  • Plt 272 x 10⁹/L (normal 130 – 380 x 10⁹/L)
  • INR and PTT normal
  • Electrolytes, extended electrolytes, urea, creatinine, glucose – normal
• Infectious
  • Influenza swab – negative
  • Blood cultures – pending
• ECG – sinus rhythm, QTc 480ms
• Imaging
  • CXR – minor fine reticular lines at costophrenic angles bilaterally, consistent with fibrosis or emphysematous change
  • CT head – nil acute
  • CT angio chest – no PE, extensive airway inflammation with patchy ground glass nodularity diffusely in sub-pleural distribution. Bronchitis and bronchiolitis, likely infectious etiology. Interlobular septal thickening most pronounced in lung bases. Mild bilateral hilar lymphadenopathy
• Procedures
  • Lumbar puncture – WBC count 50 cells/µL, 63% neutrophils, 30% lymphocytes, 6% monocytes, 1% eosinophils, RBC count 1840 cells/mm³, no organisms on gram stain, gluc 4.4 mmol/L, protein 0.35 g/L, opening pressure not recorded

Discussion #1 @6:25 – Initial broad differential

Differential	Factors For	Factors Against
1. Viral meningoencephalitis – Enterovirus* – Herpes simplex* – Varicella zoster – HIV	– Abnormal CSF – Meningismus – Acute illness progression – Could involve lungs – Rash on palms and soles could be secondary to coxsackievirus
2. Bacterial meningitis – Streptococcus pneumoniae*  – Nisseria meningitidis*  – Haemophilus influenzae – Listeria monocytogenes – Neurosyphilis – Lyme disease  – Q fever – Mycobacterium – Invasive group C strep	– Abnormal CSF – Meningismus – Acute illness progression – Could involve lungs – Son-in-law recent episode of bacterial meningitis – Rash on palms and soles could be secondary to syphlis – Antibiotic prophylaxis could be confounder – TB risk factor – exposure to indigenous communities – Q fever risk factor – contact with animals	– CSF not classic but does not rule out
3. Fungal meningitis – Cryptococcus – Coccidioides	– Meningismus – Abnormal CSF – Could involve lungs	– No evidence of immunocompromise – Acute illness progression
4. Inflammatory – Neurosarcoidosis  – SLE	– Abnormal CSF – Could involve lungs	– Acute illness progression
5. Drug-induced meningitis	– Abnormal CSF – In last month, cephalexin, carbamazepine, pregabalin started – Could involve lungs – Could cause drug rash	– Diagnosis of exclusion, need to rule out other causes

More information

• Investigations
  • Infectious
    • Blood, CSF, sputum cultures – negative
    • Respiratory virus panel – negative
    • HIV – negative
    • Cryptococcus antigen – negative
    • HSV PCR, VZV PCR on CSF – negative
    • Acid fast stain – pending
    • Hantavirus PCR – pending
    • Coxiella burnetti serology – pending
    • Legionella urinary antigen – pending
  • Rheumatologic
    • ANA, ANCA – negative
  • Hematologic
    • Peripheral eosinophil count – 0.9 x10⁹ cells/L

Discussion #2 @21:06 – Narrowing the differential and considering new eosinophilia

More information

• Investigations
  • Imaging
    • MRI brain – minimal meningeal enhancement, no other intracranial abnormalities
  • Procedures
    • Bronchoscopy –
      • BAL – 33% monocytes, 19% eosinophils, 19% neutrophils, 3% basophils, 26% lymphocytes. Atypical cells, query reactive vs malignant
      • Cytology and cytometry – negative for malignancy
      • Gram stain and culture – scant candida growth
      • No biopsy done
  • Infectious
    • Fungal culture on CSF – negative
    • Stool ova and parasites – negative
    • Strongyloides serology – negative
    • Mycobacterial culture and AFB – negative
    • Legionella urine antigen – pending
    • Hantavirus PCR – pending
    • Coxiella burnetti serology – pending
  • Hematologic
    • Peripheral eosinophil count 1.1 x 10⁹ cells/L

Discussion #3 @30:55 – Final differential

Differential	Factors For	Factors Against
1. Drug reaction – Most likely Carbamazepine	– Abnormal CSF – In last month, cephalexin, carbamazepine, pregabalin started – Could involve lungs – Could cause drug rash – Could cause eosinophilia – Rapid improvement following stopping Carbamazepine
2. Viral meningoencephalitis – Hantavirus, coxiella burnetti serology pending	– Abnormal CSF – Meningismus – Acute illness progression – Could involve lungs	– No virus identified yet – Would not explain eosinophilia
3. Bacterial meningitis – Coxiella burnetti serology pending	– Meningismus – Acute illness progression – Could involve lungs – Improvement could be delayed response to previous antibiotics	– No bacteria identified yet – Would not explain eosinophilia

More information

• Investigations
  • 10 days post-discharge – Coxiella burnetti IgM – positive, IgG – negative