Case of the month


      Each month, we will present a challenging Case of the Month for The Green Journal readers, who must use their clinical acumen to arrive at the correct answer. We will also post the case each month on the Journal’s web site ( Several possible answers may be consistent with the case presentation; use your best judgment. Please send your answer (one per respondent) and indicate the case to which you are responding to The Green Journal at [email protected] or via FAX to (415) 447-2799. Only those answers with a complete mailing address will be considered. The correct answer will appear in the January issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Drs. Mateo, Goldman, and Gantz in Philadelphia are not eligible for this month’s case. We will offer special recognition to the clinicians with the most correct answers at the end of the year. If you would like to contribute a case, please submit a brief synopsis (<250 words) to the editorial office. An individual may win only onceper calendar year.
      A 60-year-old man presented to the emergency department with new-onset seizures. He was in his usual state of good health until 2 days earlier when he developed fever, rhinorrhea, headache, arthralgias, and poor sleep. On the morning of admission he had a witnessed tonic-clonic seizure. His past medical and surgical histories, and his family history, were unremarkable. His medications included aspirin and pseudoephedrine for chronic sinus congestion. He had no allergies. He had stopped smoking cigarettes 6 years earlier, and drank 2 cases of beer per week and 1 or 2 shots of whiskey daily. His last use of alcohol had been about 24 hours before the seizure. There was no history of recent travel or exposure to pets. There were no known risk factors for exposure to the human immunodeficiency virus (HIV).
      Upon arrival at the emergency department, his vital signs included a temperature of 38.3°C, a blood pressure of 130/67 mm Hg, a pulse of 92 beats per minute, a respiratory rate of 20 breaths per minute, and a room-air oxygen saturation of 91%. There were no signs of head trauma; the neck was supple. The lungs were clear to auscultation and the heart sounds were normal. The abdomen was soft and was without organomegaly. There was full range of motion of all joints, without erythema or effusion. The skin was normal. He was alert and oriented to name and time, but not place; however, he was somewhat inattentive and withdrawn. Comprehension of speech appeared normal, as did his ability to repeat words and phrases, but his spontaneous speech was somewhat delayed. The remainder of the neurological examination, including cranial nerves, reflexes, sensation, strength, and coordination, was normal.
      The white blood cell count was 6,900 per μL, with 72% neutrophils, 16% band forms, 5% lymphocytes, and 6% monocytes. The hemoglobin level was 11.0 g/dL and the platelet count was 174,000 per μL. Serum electrolyte, glucose, creatinine, and aminotransferase levels were normal, as were the prothrombin and partial thromboplastin times. An electrocardiogram was normal. A chest radiograph disclosed bullous emphysema without pulmonary infiltrates. A computed tomographic (CT) scan of the head, without the use of contrast, was normal. Examination of the cerebrospinal fluid revealed 26 red blood cells and no white blood cells per mL; the glucose level was 95 mg/dL and the protein level was 36 mg/dL. Gram stain and India ink stains revealed no organisms, and antigen studies for Hemophilus influenza type B, Streptococcus group B, S. pneumoniae, Neisseria meningitidis groups A, B, C, and W135, and Escherichia coli, were negative. Cultures of the blood and cerebrospinal fluid were sterile. An electroencephalogram showed moderate generalized slowing with a diffuse disturbance of brain function; no lateralizing or epileptiform features were noted.
      The patient was treated with parenteral acyclovir on the first hospital day and parenteral ceftriaxone during the first four hospital days, but he remained febrile. He was also treated with thiamine, folate, phenytoin, and lorazepam. He remained confused with a delayed response to questions.
      What further work-up and treatment are indicated? What is the most likely diagnosis?

      Answer to the November case of the month

      Last month’s patient with abdominal pain, hyponatremia, and seizures had acute intermittent porphyria. A Watson-Schwartz test for urinary porphobilinogen was strongly positive; fecal excretion of porphyrins was normal.
      There were no correct answers to the September case (cavernous sinus thrombosis).