12th August 2024

A 76-year-old gentleman from Pakistan presents with confusion. His partner reports he has been unwell for the last 14 days

A 76-year-old gentleman from Pakistan presents with confusion. His partner reports he has been unwell for the last 14 days with a headache, fatigue and fevers. His symptoms have worsened and for the last 3 days he has been complaining of neck stiffness, photophobia and nausea.  They also report that he has lost a significant amount of weight over the last 6 months. He has a past medical history of type 2 diabetes mellitus. On examination, he is confused and on assessment of eye movements he is unable to abduct his right eye. A lumbar puncture is performed and the CSF is noted to be very cloudy. Empirical treatment for presumed bacterial meningitis is started. However, he continues to deteriorate, developing seizures and reduced GCS (Glasgow Coma Scale). The initial CSF report shows 150 WBC/mm³, which are predominantly lymphocytes, protein 0.55 g/L and glucose of 4.8 mmol/L.

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