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A 72-year-old diabetic is transferred to your hospital
for fever and altered mental status in the late
summer. Symptoms started in this patient 1 week
prior to admission. On physical examination, the
patient was disoriented. There were no focal neurologic
findings. There was a fine rash on the patient’s
trunk. On oral examination, there were tongue
fasciculations. A lumbar puncture was performed
which showed a glucose of 71 and a protein of 94;
microscopy of the cerebrospinal fluid (CSF)
revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The
creatinine phosphokinase was 506. An electroencephalogram
and MRI of the brain were normal.
1. What is the best interpretation of these
(A) The patient may have cryptococcal
(B) The patient may have disseminated
(C) The patient may have West Nile virus.
(D) The patient may have Coccidioides immitis
(E) The patient may have rhinocerebral
2. What further diagnostic test is the most
(A) Perform a West Nile virus IgM on the
(B) Perform a serum cryptococcal antigen.
(C) Perform C. immitis complement fixation
(D) Perform a sinus series.
(E) Perform a purified protein derivative
(PPD) skin test.
u can check and compare it with normal
gluc.71, prot 94,9 rbcs, 14 wbcs in which in which 21 % is polymorpho
E and D ?
This is a clinical presentation of West Nile
virus infection. The tongue fasciculations go
along with an inflammation at the base of the
brain. The patient is at the right age for West
Nile virus infection and he is immunocompromised
due to diabetes.
The diagnosis can be made by performing a West Nile virus IgM
titer on the CSF
Diabetics can have cryptococcal meningitis. Lumbar puncture in this setting
is usually normal with increased opening pressure, and rhabdomyolysis is not a feature
of this disease.
Diabetics are more at risk for candidiasis. However, the patient has no history
of instrumentation, IV catheters, or other situations that would lead to disseminated
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