Figure 1. List of patient’s medications at admission.
Upon admission the patient was started on empirical ceftriaxone 1 g IV every 12 hours. On day 3 of admission she developed high grade fever reaching 39°c, and was switched to pipercillin/tazobactam 4.5 g IV every 6 hours by respiratory team due to suspicion of hospital acquired pneumonia, further septic workup including sputum culture, respiratory panel and Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) screening were all negative.
Magnetic resonance imaging (MRI) lumbar spine revealed spondylo-degenerative changes noted at L1-L2, L2-L3, L4-L5, with no significant disc bulge or nerve roots compression.
On day 8 of admission the fever persisted and the patient developed confusion and disorientation to place and person. Metabolic workup was non-contributory. Brucella, malaria and Mycobacterium tuberculosis work up all came negative. Lumbar puncture was performed with following results:
Cerebral spinal fluid (CSF) results:
CSF wbc: 1 (0-5)
CSF rbc: 425 (0-20)
CSF protein: 226 mg/L (150-450)
CSF glucose: 4.4 mmol/L (serum glucose 6.5 mmol/L)
CSF Mycobacterium tuberculosis Polymerase Chain Reaction (MTB PCR) GeneXpert and Ziehl–Neelsen stain were negative
Computed tomography (CT) of chest with contrast was remarkable for an enlarged heart and pulmonary trunk, minimal right sided pleural effusion/thickening. CT brain, abdomen and pelvis were unremarkable
The patient was started by neurology team on intravenous immunoglobulin (IVIG) at a dose of 0.4 mg/killogram/day for the suspicion of Guillain-Barré syndrome, however it was stopped after 3 days due to persistent fever. After IVIG discontinuation the patient became afebrile.
On day 13 of admission patient was afebrile with normal vitals however her level of consciousness continued to deteriorate and became obtunded and was shifted to intensive care unit, and her antibiotic was escalated to meropenem 1 g IV every 8 hours and vancomycin 1 g IV every 12 hours. She was reviewed by infectious disease team with suspicion of beta lactam induced encephalopathy; therefore meropenem and vancomycin were stopped and she was kept on Trimethoprime/sulfamethaxazole (Bactrim) 960 mg orally twice daily based on previous urine culture and sensitivity. Repeated septic work up remained negative.
Within 24 hours patient became alert and oriented to place and person, with normal vitals and was shifted to general ward. The remaining of hospital stay was uncomplicated. Patient received regular physiotherapy and her lower limb weakness improved and was able to mobilize with assistance as her baseline. The patient was discharged home after completing 7 days of Bactrim and to continue home physiotherapy.