Medical Knowledge Sharing Center: A Misdiagnosis: Sleepiness and Severe Headache

Mark Crislip, MD

Authors and Disclosures

Posted: 09/02/2011

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Clinical Presentation

A 28-year-old Gambian man presents with progressive headache and lower-extremity weakness.

History and Physical Examination

History. The patient's progressive headache started 2 weeks prior to admission. It slowly advanced from mild to severe and constant and became global with photophobia and a stiff neck. Five days prior to admission he was seen in the emergency department where, after a lumbar puncture, he was told that he had viral meningitis (it was September, enteroviral season). For 2 days prior to admission he had had progressive lower-extremity weakness.

Review of symptoms: no constitutional or other symptoms
Remote medical history: none
Medications: none
Allergies: none
Habits: none
Pets: none
Diet: regular
Travel: born and raised in rural Gambia; has been in the United States for about a year
Social: married; no children
Immunizations: up to date
Sports/water exposure: none
Infectious disease exposure: PPD negative 3 months ago

Physical examination. On physical examination, the following were noted:

Vital signs: temperature: 97.9º F; pulse: 89 beats/min; respirations: 20 breaths/min; blood pressure: 126/67 mm Hg
General: sleepy but arousable
HEENT: normal, except for stiff neck
Lungs: clear
Heart: normal
Abdomen: nontender without masses or organomegaly
Extremities: normal
Skin: multiple scars
Neuro: oriented to person, place, and time. Sleepy but responds appropriately. Cranial nerves intact. Upper extremities normal. Proximally in the quadriceps and iliopsoas muscle strength was 5/5, and the patient was able to bear weight and ambulate. Cerebellar examination was normal for finger-to-nose testing and he had bilateral positive Babinski (upgoing toes) sign. Reflexes were 1+ in the upper extremities, 2+ at the right knee jerk, 1+ at the left knee jerk, 2+ at the ankle, with 2-3 beats of clonus. Tone was normal without atrophy or vesiculation. Gait was wide-based. Tandem gait could not be performed.

Diagnostic Evaluation

Lab results. The following results were obtained:

WBC: 4 x 10³/mm³
Hgb: 10.9 g/dL
Differential: normal
Hemoglobin A1c: normal
Glucose: 105 mg/dL
Bilirubin: 0.3 mg/dL
Calcium: 8.5 mg/dL
Albumin: 3.2 g/dL
Total protein: 10.4 g/dL
Alkaline phosphatase: 78 U/L
ALT: 25 U/L
AST: 36 U/L
Urinalysis: normal

Lumbar puncture

CSF collected before admission: WBC 254 x 10³/mm³ with 9 RBCs, 42 neutrophils, 42 lymphocytes, 16 monocytes. CSF glucose: 11 mg/dL. CSF protein: 185 g/dL. Gram stain negative.
CSF collected upon admission: WBC 112 x 10³/mm³, similar differential, CSF glucose 21 mg/dL, and CSF protein 234 g/dL.

Diagnostic Imaging

Chest x-ray: clear
MRI of spine; radiologist report: "Enhancement of CSF consistent with inflammatory change. No focal lesions observed. No focal enhancement. No evidence of a cord compression. When images before and after infusion of paramagnetic contrast are compared, there is fairly gross enhancement of the CSF in the thoracic and lumbar portions of the spine. This is less obvious to nonexistent at the cervical level and in the vicinity of the craniocervical junction."