A questionable diagnosis in a woman with drowsiness

Abstract

A 60-year-old caucasian woman was admitted to our Division of Internal Medicine for a 10-day history of drowsiness, irritability, dysphasia, weakness and difficulties in the maintenance of an upright position with numerous falls, with a traumatic lumbar spine injury and on the left shoulder. Then, while general clinical conditions were getting worse with drowsiness and hyposthenia of the right side of the body, after neurological evaluation, she was recovered in hospital. Pathological history includes a 20-year epilepsy and depression with emotional lability, behavior’s disorders and attempted suicide. For such reason, she was followed in a mental health institute, treated with phenobarbital (150 mg/ die) and for two months with escitalopram (10 mg/die), valproic acid (1000 mg/die), diazepam (4 mg, on demand), as antidepressant as well. At admission, the patient appeared in bad clinical conditions, not alert and not oriented in the space-temporal parameters, drowsy but responsive to verbal stimulation. She was apiretic, the arterial blood pressure was around 80/50 mmHg, the pulse rate 80 bpm, eupnoeic with an oxygen saturation of 97% breathing in ambient air. On neurological examination, there were not side marks, but there was the presence of neck stiffness, with dystonic and forced neck position, overtone of the fourth limbs, dysphasia. Routine laboratory tests showed an increase of CRP and raised serum aminotransferases till 12–17 upper normal limits, gammaglutamyl—transpeptidase till 4–6 UNL. Serology for hepatotropic viruses showed a previous infection of CMV, EBV, HAV, HBV (with IgG positive and IgM negative, DNA negative, Anti-HbsAb positive, HBsAg negative) and HCV, HSV negativity. For the fever upcoming just after the recovery, blood culture for aerobes, anaerobes and fungi were performed; furthermore, considering neck stiffness, with dystonic and forced neck position lumbar puncture for N. meningitides, Mycobacteria, E. Coli, S. Pneumoniae, Streptococcus B,have been done. We searched for vegetations and endocarditis at echocardiography. CT of chest and of brain were performed to evaluate pneumonia, cerebrovascular disease and the eventual presence of traumatic wounds of the crane, as well; CT scan of spinal cord, ankle,