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Endgames Case Review

Fever with seizure and confusion

BMJ 2016; 353 doi: (Published 14 April 2016) Cite this as: BMJ 2016;353:i2023
  1. R Nandhagopal, associate professor of neurology
  1. Neurology Unit, Departments of Medicine, College of Medicine and Health Sciences, PO Box 35, SQU, Al-Khod, Zip 123, Muscat, Oman
  1. Correspondence to: R Nandhagopal rnandagopal{at}

A 41 year old previously healthy man presented with a six day history of fever, headache, and vomiting, followed by two episodes of staring spells and unresponsiveness and secondarily generalised tonic-clonic seizures. In the emergency department he was restless, inattentive, and not oriented to time, place, and person (Glasgow coma score 10/15; best eye opening response (E): 3; best motor response (M): 5 and best verbal response (V):2). He had neck stiffness; Kernig’s sign was positive and his ocular fundi were normal. He had no limb weakness or ataxia and deep tendon reflexes and plantar reflexes were normal. He tested negative for HIV1/2 antigen and antibody. His blood coagulation profile and platelet count were normal. An initial unenhanced computed tomogram of the brain found no contraindications for lumbar puncture. Analysis of cerebral spinal fluid (CSF) showed glucose 3.4 mmol/L (reference range 2.2-3.9 mmol/L; corresponding blood glucose was 5.8 mmol/L), protein 2.59 g/L (0.15-0.45 g/L), 450×106 white blood cells/L (100% lymphocytes; 0-5×106), and 40×106 red blood cells/L. Gram staining of the CSF was negative and bacterial culture was sterile. A confirmatory microbiological test was performed on his CSF and computed tomography of the brain repeated the second week after the onset of symptoms (fig 1).

Fig 1 Unenhanced cranial computed tomograms at the level of the temporal lobe (A) and insula (B)


  1. What abnormalities are seen in fig 1?

  2. How do you interpret the …

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