A 56 year old man with headache, fever, and neurological symptoms

A previously fit and well 56 year old retired mechanic was admitted to hospital via the emergency department with a one week history of headache. He described the headache as being “moderately” severe and affecting his entire head. There were no exacerbating or relieving factors, and he had not had a similar headache previously.

The day before admission he developed double vision, neck stiffness, and vomiting. On the day of admission he developed drooping of the right side of his face, weakness of the right leg, and difficulty walking, with some impairment of balance. He had no history of fevers, rigors, or other systemic symptoms before admission. He had not recently travelled and had no unwell contacts. His medical history was unremarkable.

On examination he had a score of 15/15 on the Glasgow coma scale. His temperature was 38.5°C, his blood pressure was 135/68 mm Hg, and his pulse rate was 90 beats/min. He had moderate neck stiffness and a right sided facial droop indicative of a lower motor neurone seventh cranial nerve palsy. He also had subtle pass pointing and ataxia in the right upper limb, with mild heel-shin ataxia in the right lower limb consistent with right sided cerebellar signs. The remainder of the neurological examination was unremarkable.

Blood tests on admission showed a peripheral white blood cell count of 17.7×10⁹/l (neutrophils 15.55×10⁹/l), C reactive protein 120 mg/l, and normal urea and creatinine. His serum sodium was slightly decreased at 131 mmol/l.

Computed tomography and lumbar puncture were performed on admission. Magnetic resonance imaging was performed the next day (fig 1⇓). Analysis of his cerebrospinal fluid showed protein 0.96 g/l, glucose 1.2 mmol/l, and white cell count 535/mm³ (85% polymorphs, 10% lymphocytes, 5% atypical white cells). No organisms were seen on Gram …