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14th June 2023
A 45-year-old male presented to A&E with history of fever, headache, photophobia, and neck stiffness for 2 days
A 45-year-old male presented to A&E with history of fever, headache, photophobia, and neck stiffness for 2 days. He had a history of splenectomy for immune thrombocytopenic purpura (ITP). On assessment, he was febrile at 38˚C, tachycardic at 110 bpm, BP 110/60mmHg, and O2 saturation 97% on air. Neck stiffness was present, but no rashes were noted. GCS 14/15 (E4, V4, M6). No focal neurology present. Kernig’s sign positive.
Investigations are as follows:
Bloods:
| Hb | 145 g/L | Male (130-180 g/L) |
| White count | 13.4 x 10⁹ | (4.0-11.0 x 10⁹) |
| Platelets | 400 x 10⁹ | (150-500 x 10⁹) |
| Sodium | 133 mmol/L | (135 -145 mmol/L) |
| Potassium | 4 mmol/L | (3.5-5 mmol/L) |
| Urea | 2.5 mmol/L | (2.5-6.7 mmol/L) |
| Creatinine | 100 μmol/L | (68-150 μmol/L) |
| GFR | >90 ml/min | (>90 ml/min) |
| Calcium | 2.3 mmol/L | (2.05- 2.6 mmol/L) |
| Bilirubin | 10 μmol/L | (3-17 μmol/L) |
| AST | 35 IU/L | (8-40 IU/L) |
| ALP | 13 IU/L | (10-50 IU/L) |
CSF analysis:
| Appearance | Cloudy | |
| Protein | 0.56 g/L | (<0.45 g/L) |
| Glucose | 2.4 mmol/L | (2.5-4.4 mmol/L) |
| White cells | 200 cells/μL (predominantly polymorphs) | (<5 cells/μL) |
Of the options below, which single answer is the most likely underlying cause?
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