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A 68- year-old woman with headache and photophobia


A 68- year-old woman with headache and photophobia


حالة سريرية

الشكوى الرئيسية CC
This 68-year-old, right-handed woman was admitted to the
hospital because of headaches that began about one
month earlier.
القصة المرضية HPI
She was in good general health. About one month prior to
admission she developed progressively severe headaches
and vertigo
(a sensation that her environment was spinning
around her). Shortly after the onset of these complaints,
she noted photophobia (discomfort from light, to the extent
that room lighting caused her eyes to hurt). The photopho-
bia increased to the point that she had to wear sunglasses
to cope with Christmas tree lights indoors. She was
observed by her family to become increasingly lethargic
(drowsy) and forgetful, prompting her hospitalization.
الفحص السريري Clinical Exam
Physical examination revealed a lethargic woman who was
oriented to person and place but not to time. (She knew her
name and where she was, but not the month or the year or
that Christmas and New Year's Day had just passed.) The
temperature was 98.9°F. There was moderate resistance to
anterior flexion of her neck beyond 60
° . The lungs had
crackles at both bases (consistent, in this instance, with
findings described below in the chest X-ray). Neurologic
examination revealed pain when her straightened legs were
raised beyond 45 ° (evidence, with the resistance to neck
flexion, that there was at least moderate inflammation of
the meninges). In addition, when reaching for objects with
her hands, she consistently over-reached and missed them
("past-pointing," indicative of cerebellar dysfunction). This
latter finding was worse on the left than on the right.
الاستقصاءات Investigations
Computerized tomography of the head revealed only mild
cerebral atrophy (shrinkage--probably age-related).
Because of the signs of meningeal irritation, a lumbar punc-
ture was performed shortly after admission to the hospital.
The peripheral white blood cell count was 11,800/pl (normal
between 5000 and 10,000), with 83 percent polymorphonu-
clear leukocytes, 9 percent band forms, 4 percent lympho-cytes,
and 4 percent monocytes (a slight increase in imma-
ture granulocytes, suggesting an acute inflammatory pro-
cess somewhere within the patient). The chest X-ray
revealed diffuse interstitial infiltrates of both lower lobes
(that is, increased fluid in the septa separating very minute
air spaces).
The cerebrospinal fluid (CSF) obtained during the lumbar
puncture was clear and colorless, with a total white blood
cell count of 18/pl (normal up to 4), with 75 percent poly-
morphonuclear leukocytes and 25 percent lymphocytes.
(Polymorphonuclear leukocytes are never normally present
in CSF.) The CSF glucose was 28 mg/dl with simultaneous
blood glucose of 119 mg/dl. (The blood glucose was within
normal limits; but CSF glucose considerably less than 50
percent of blood glucose suggests that a viable micro-
organism is present in the subarachnoid space.) The CSF
protein concentration was 58 mg/dl (very slightly above the
upper limit of normal for this patient's age).
كتابة حرة وطرح موضوع النقاش!
While performing the white blood cell count on the CSF, an
alert laboratory technician observed structures that did not
resemble white blood cells. A sample of CSF was cen-
trifuged and the sediment resuspended in India ink. Under
the microscope, in dramatic relief among the India ink parti-
cles, were the organisms shown in the figure.

The most likely etiology of this patient's meningitis is:
A. Streptococcus pneumoniae.
B. Candida albicans.
C. Histoplasma capsulatum.
D. Clostridium perfringens.
E. Cryptococcus neoformans

to be continued
.

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by
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Cryptococcus neoformans؟

.b's picture
.b
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Quote:
Cryptococcus neoformans؟

great

The organism that grew from cultures of CSF and blood
was Cryptococcus neoformans. Despite very aggressive
therapy with amphotericin B, both intravenously and
instilled directly into a lateral cerebral ventricle, the patient
followed a relentless downhill course and died on the eighth
day of treatment. Autopsy confirmed severe meningitis due
to Cryptococcus neoformans.

mbs2380's picture
mbs2380
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Discussion[i]: Invasive disease due to this organism is
strongly suggestive of a defect in cell-mediated immunity,
and its presence in this patient caused the clinicians caring
for her to suspect that she had a malignant lymphoma.
(This patient was treated in the early 1980s, prior to the
emergence of human immunodeficiency virus (HIV) as a
significant cause of severely impaired cell-mediated immu-
nity. Moreover, she had none of the known risk factors that
might lead to HIV infection.) In addition to the cryptococcal
disease itself, autopsy revealed a clinically inapparent
malignant lymphoma that was limited to the patient's uri-
nary bladder and fallopian tubes.

The lymphoma did not cause this patient's death the way
many cancerous tumors do, that is, by causing failure of a
vital organ. Instead, the profound defect in cell-mediated
immunity that accompanies lymphomas
(as well as a num-
ber of other clinical entities) created in this patient a predis-
position to infection with an organism whose progression
she could not resist
. As Cryptococcus neoformans often
does, it attacked her central nervous system preferentially.
By the time this infection created clinical symptoms of
headache, photophobia, and vertigo, it had passed the
point of reversibility, and caused her death.

It is characteristic of malignancies that are accompanied by an
immune defect that death is the result of an overwhelming
infection. By correlaling the immune defect with the underlying
disease, one may often anticipate the complicating infection,
and intervene in time to enjoy a favorable clinical outcome.
Or, as with this patient, the presence of an opportunistic infeclion (one that takes particular advantage of individuals with an
immune compromise) may herald the clinical onset of an
immune-compromising disease. It is therefore quite important
to be able to match an organism with the list of illnesses asso-
ciated with the corresponding immune defect.
[b]
-

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mbs2380
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thanks

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.b
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