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1、CaseoftheMonth—Patient#51HistoryPresentIllness:A40yearoldhomemaker,previouslyingoodhealth,experiencedatransientepisodeofleft-sidedface,arm,andlegnumbnesslastingabout10minutes.Thefollowingday,shedevelopedrecurrentleft-sidednumbness,withspeechdisturbancedescribedasdifficultyw
2、itharticulatingwords.Shewastakentoanearbyhospital,butonarrival,hersymptomsofnumbnessanddysarthriahadspontaneouslyresolved.Acomputedtomographicscanoftheheadwasreportedasnormal,andthepatientwasadmittedforobservation.Thefollowingmorningat2a.m.,shedevelopedaseizuredescribedbyan
3、urseas"grandmal,"lastingabout30secondswithtonguebitingandbladderincontinence,andfollowedbytransientconfusionandaphasia.Electrolytesandacompletebloodcountwerewithinnormallimits.Alumbarpuncturewasperformed,revealingclear,colorlesscerebrospinalfluidwithglucose72mg/dl,protein55
4、mg/dl,0whitebloodcells,and0redbloodcells).AnMRIstudyoftheheadwithdiffusion-weightedandFLAIRsequenceswasreadasnormal,andanelectroencephalogramlikewiseshowednoabnormalities.Phenytoinwasinitiated,andthepatientreturnedtoherbaselinementalstatus.Onthethirdhospitalday,thepatientde
5、velopedalow-gradefever(temperatureto102F)anddeliriumwithpsychoticfeatures.Shewasabletofollowcommands.Achestx-rayrevealedpatchyinfiltratesintheleftlowerlobe.Shewastreatedwithceftriaxoneandclindamycinforapresumedaspirationpneumonia,andwitholanzapineformanagementofpsychoticsym
6、ptoms.Herfeverpersisted,andshebecameaphasic,withdiminishedresponsiveness.Bloodandurineculturesshowednogrowth.Doxycycline,acyclovirandmethylprednisolonewereaddedtohermedicalregimen,andthepatientwasintubatedforairwayprotection.Asecondlumbarpuncturewasperformed,revealingclear,
7、colorlesscerebrospinalfluidwithanopeningpressureof26cmH2O,withglucose81mg/dl,protein80mg/dl,0whitebloodcells,and0redbloodcells.ArepeatEEGshoweddiffuseslowingwiththedevelopmentofaburst-suppressionpattern.Onthesixthdayofherhospitalization,thepatientwastransferredtotheBenTaubG
8、eneralHospitalforfurtherevaluationandmanagement.OninitialexaminationintheICU,thepa
