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A 65-year-old Caucasian man with type 2 diabetes mellitus presented to the emergency department with subacute altered mental status, preceded by a 2-month history of progressive weight loss, anorexia and fever. He was febrile with a temperature of 38.5°C, but general medical examination was otherwise normal. He was disorientated with cognitive slowing, with no meningism or focal signs. CT scan of head was normal. Cerebrospinal fluid (CSF) examination showed a normal opening pressure (18 cm H2O), lymphocytic pleocytosis (73 cells/µL), glucose 2.9 mmol/L (26% of glycaemia), and protein 0.93 g/L. CSF smear found no organisms on Gram or Ziehl–Neelsen stain. We started empirical treatment for meningoencephalitis with intravenous ampicillin, ceftriaxone and acyclovir, but there was no clinical improvement in the following days.
MR scan of brain showed scattered white …
Contributors MF: data collection, conception and drafting the manuscript for intellectual content and review of final form. BM, JPM, ASC: contributed to patient care and revision of the manuscript. JC: data collection, critical review. M-VB: approval and critical review of final form.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed by Ben Turner, London, UK and Nick Davies, London, UK.