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NewYork-Presbyterian Hospital Psychiatry
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Case of the Month - March 2018

This 46 year old female was brought in by EMS after erratic behavior and change in mental status.

The provider’s differential diagnosis was acute bacterial meningitis/encephalitis vs subarachnoid hemorrhage vs stroke vs metabolic/toxic etiology.

Question 1 : The head CT below was somewhat suggestive of one of the above diagnoses. Can you tell which one and why?

View answer
Answer 1:

The ct read included the following “Decreased number of sulci in bilateral frontal, parietal, occipital and temporal lobes with mild hydrocephalus. This is non-specific but can be seen with infection such as meningitis.” (see image below)

This patient’s LP showed opening pressure 45, first tube with 11678 WBCs, glucose 33, protein 487. The CSF PCR grew Strep pneumo. She was treated empirically with dexamethasone, acyclovir, ampicillin, ceftriaxone and vancomycin which was eventually de-escalated to vancomycin and ceftriaxone. She was discharged in stable condition 4 days later.

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