An MRI of the total spine also showed leptomeningeal enhancement ( Figure 1). A repeat MRI of the brain on hospital day 5 demonstrated an evidence of basilar meningitis, interval development of hydrocephalus, persistent leptomeningeal enhancement, most prominent in the bilateral frontal lobes, and the previously seen left anterior cerebral artery territory infarct. On examination upon transfer, the patient was intubated, over-breathing the vent, with no corneal reflex, no gag, no cough, extension in the upper extremities, and triple flexion in the lowers. His lethargy worsened over 3 days, requiring intubation and transfer to our intensive care unit (ICU). An MRI of the brain with contrast showed leptomeningeal enhancement as well as a left anterior cerebral artery infarct. He was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. The head CT without contrast was unrevealing a lumbar puncture showed a white blood cell count of 190 with a monocytic predominance (87, 13% polymorphonuclear cells), red blood cell count of 44, glucose of 18, and protein of 235.
Despite this treatment, his symptoms continued to worsen over 2 weeks, and he became more lethargic, resulting in his initial presentation to the hospital. A few days afterwards, he started complaining of non-specific upper respiratory symptoms, including cough and sinus congestion, for which he went to an urgent care and received amoxicillin. He was in his usual state of health until 2 weeks prior to presentation when he attended an Albanian cultural festival. The patient was a 62-year-old male with a history of Parkinson's disease and who was admitted to a community hospital with an altered mental status.
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