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.