Case Records of the Massachusetts General Hospital
Case 12-2012 — A 10-Month-Old Girl with Vomiting and Episodes of Unresponsiveness
…, urinalysis, urine and blood cultures and toxicology testing, electrocardiography, preparation for obtaining cerebrospinal fluid by means of lumbar puncture, and MRI of the head. Intravenous lorazepam was kept at the bedside in case of seizure activity. Initial test results showed an elevated white…
April 19, 2012
Sassower K.C., Allister L.M., Westra S.J.
N Engl J Med 2012; 366:1527-1536
Case Records of the Massachusetts General Hospital
Case 15-2012 — A 48-Year-Old Woman with Diplopia, Headaches, and Papilledema
…sheaths. A lumbar puncture was performed; analysis of the cerebrospinal fluid (CSF) is shown in Table 1. No bacteria, acid-fast bacilli, or fungal organisms were seen on smears or cultures, and cytologic examination revealed no malignant cells. The next day, MRI of the cervical, thoracic, and lumbar spine…
May 17, 2012
Venna N., Coyle C.M., González R.G., Hedley-Whyte E.T.
N Engl J Med 2012; 366:1924-1934
Case Records of the Massachusetts General Hospital
Case 8-2012 — A 53-Year-Old Man with Crohn's Disease, Diarrhea, Fever, and Bacteremia
…causative organism in a proper host and initiate early antibiotic therapy in patients who have symptoms of meningitis. I generally recommend lumbar puncture in cases like this, because it can be useful in managing the duration of antibiotic therapy, even if patients do not have signs and symptoms of…
March 15, 2012
Hohmann E.L. and Kim J.
N Engl J Med 2012; 366:1039-1045
Case Records of the Massachusetts General Hospital
Case 1-2013 — A 63-Year-Old Man with Paresthesias and Difficulty Swallowing
…tremulous, agitated, oriented but confused, and unable to give a clear history. After premedication with additional lorazepam and haloperidol, a lumbar puncture was performed. The opening pressure was 33 cm of water. Results of cerebrospinal fluid (CSF) analysis and other test results are shown in Table…
January 10, 2013
Greer D.M., Robbins G.K., Lijewski V., Gonzalez R.G., McGuone D.
N Engl J Med 2013; 368:172-180
Case Records of the Massachusetts General Hospital
Case 18-2011 — A 35-Year-Old HIV-Positive Woman with Headache and Altered Mental Status
…dorsal pons. IgG antibodies to herpes simplex virus type 2 (HSV-2) were present in the serum; results of analysis of the CSF that was obtained by lumbar puncture are shown in Table 1. A diagnosis of Mollaret's meningitis (recurrent aseptic meningitis usually caused by members of the family Herpesviridae…
June 16, 2011
Costello D.J., Gonzalez R.G., Frosch M.P.
N Engl J Med 2011; 364:2343-2352
Case Records of the Massachusetts General Hospital
Case 29-2012 — A 49-Year-Old Man with Pain and Cranial-Nerve Palsies after Treatment of Oral Cancer
…slightly decreased enhancement in the right cavernous sinus that measured 1.2 cm in diameter and was centered on the right internal carotid artery. Lumbar puncture was performed. Analysis of the cerebrospinal fluid (CSF) is shown in Table 1; testing for Lyme disease, herpes simplex virus (HSV), and syphilis…
September 20, 2012
Wirth L.J., Plotkin S.R., Emerick K.S., Cunnane M.E., Faquin W.C.
N Engl J Med 2012; 367:1136-1147
Case Records of the Massachusetts General Hospital
Case 4-2011 — A 4-Year-Old Boy with Back Pain and Hypercalcemia
…of peripheral blasts and declining numbers of normal leukocytes, platelets, and red cells. One day after the diagnosis of ALL was confirmed, a lumbar puncture was performed, with the administration of intrathecal methotrexate. The cerebrospinal fluid did not show evidence of leukemic cells. The patient…
February 10, 2011
El Saleeby C.M., Grottkau B.E., Friedmann A.M., Westra S.J., Sohani A.R.
N Engl J Med 2011; 364:552-562
Case Records of the Massachusetts General Hospital
Case 27-2012 — A 60-Year-Old Woman with Painful Muscle Spasms and Hyperreflexia
…to have confused speech. At that time, routine laboratory testing, cultures, and toxicologic screening were negative. A specimen of CSF from a lumbar puncture showed a lymphocytic pleocytosis, with 13 white cells and 749 red cells. The CSF glucose level was normal, but the protein level was slightly elevated…
August 30, 2012
Byrne T.N., Isakoff S.J., Rincon S.P., Gudewicz T.M.
N Engl J Med 2012; 367:851-861
Case Records of the Massachusetts General Hospital
Case 5-2012 — A 39-Year-Old Man with a Recent Diagnosis of HIV Infection and Acute Psychosis
…sputum grew Candida albicans and normal respiratory flora. Cultures of sputum, urine, and blood for mycobacteria and fungi remained negative. Lumbar puncture was performed, and analysis of the cerebrospinal fluid (CSF) was normal. The HIV RNA level was 3010 copies per milliliter of CSF, with no malignant…
February 16, 2012
Freudenreich O., Basgoz N., Fernandez-Robles C., Larvie M., Misdraji J.
N Engl J Med 2012; 366:648-657
Case Records of the Massachusetts General Hospital
Case 28-2011 — A 74-Year-Old Man with Pemphigus Vulgaris and Lung Nodules
…to make the diagnosis in this case, since among HIV-negative patients, it is positive in only 56% of patients with pulmonary disease. Also, a lumbar puncture, with evaluation of the cerebrospinal fluid (CSF) for dissemination of cryptococcal infection, should be performed in this immunocompromised patient…
September 15, 2011
Mylonakis E., Muse V.V., Mino-Kenudson M.
N Engl J Med 2011; 365:1043-1050
Clinical Problem-Solving
Avoiding a Rash Diagnosis
…with Rocky Mountain spotted fever, and hyponatremia associated with a central nervous system infection may explain the patient's lethargy. A lumbar puncture should be performed immediately. Stage. A complete blood count revealed a white-cell count of 11,500 per cubic millimeter, with 79% polymorphonuclear…
February 3, 2011
Reznicek J.E., Mason W.J., Kaul D.R., Saint S., Bloch K.C.
N Engl J Med 2011; 364:466-471
Case Records of the Massachusetts General Hospital
Case 10-2011 — A Woman with Fever, Confusion, Liver Failure, Anemia, and Thrombocytopenia
…patent hepatic vasculature, and splenomegaly (19.5 cm in the craniocaudal dimension), with no evidence of cholelithiasis or cholecystitis. A lumbar puncture was performed; analysis of the cerebrospinal fluid revealed clear, colorless fluid with a glucose concentration of 37 mg per deciliter (2.1 mmol…
March 31, 2011
Tierney L.M., Thabet A., Nishino H.
N Engl J Med 2011; 364:1259-1270
Case Records of the Massachusetts General Hospital
Case 2-2013 — A 20-Year-Old Man with Recurrent Ear Pain, Fever, and Headache
…-ear cavities and the mastoid air cells, with erosion of the inferomedial wall of the right temporal bone, contiguous to the meningeal space. Lumbar puncture was performed; results of analysis of the cerebrospinal fluid (CSF) are shown in Table 1. Gram's staining of the CSF showed no organisms, and testing…
January 17, 2013
Stankovic K.M., Eskandar E., El Khoury J.B., Lev M.H., Sadow P.M.
N Engl J Med 2013; 368:267-277
Case Records of the Massachusetts General Hospital
Case 11-2012 — A 60-Year-Old Man with Weakness, Rash, and Renal Failure
…and empirically, and acetylsalicylic acid and acetaminophen were given. An electrocardiogram showed mild ST-segment and T-wave abnormalities. A lumbar puncture was performed, and results of the cerebrospinal fluid (CSF) analysis showed a normal cell count and normal protein and glucose levels. Gram's staining…
April 12, 2012
Channick R.N., Lorenzo M.E., Wu C.C., Hoang M.P.
N Engl J Med 2012; 366:1434-1443
Case Records of the Massachusetts General Hospital
Case 34-2011 — A 75-Year-Old Man with Memory Loss and Partial Seizures
…the right foot and patchy loss of sensation to pin prick in the lower legs and feet bilaterally. The remainder of the examination was normal. A lumbar puncture was performed; results of analysis of the cerebrospinal fluid (CSF) are shown in Table 1. The administration of phenytoin was begun. A diagnostic…
November 10, 2011
Cash S.S., Larvie M., Dalmau J.
N Engl J Med 2011; 365:1825-1833
Case Records of the Massachusetts General Hospital
Case 24-2012 — A 38-Year-Old Man with Abdominal Pain and Altered Mental Status
…fluid throughout the abdomen; and multiple enlarged nodes (≤1.3 cm in diameter) in the abdomen and both inguinal regions. On the second day, a lumbar puncture was performed. Analysis of the cerebrospinal fluid (CSF) revealed colorless clear fluid, with no red cells and 1 white cell per cubic millimeter…
August 9, 2012
Fathi A.T., Chen Y.-B., Carter B.W., Ryan R.J.H.
N Engl J Med 2012; 367:552-563
Clinical Problem-Solving
The Eyes Have It
…the head showed no acute hemorrhage or infarct. A CT angiogram of the head and neck revealed no evidence of arterial dissection. Results of a lumbar puncture showed a white-cell count of 2 per cubic millimeter with a normal differential count, a glucose level of 53 mg per deciliter (2.9 mmol per liter…
September 6, 2012
Vasa M., Baudendistel T.E., Ohikhuare C.E., et al.
N Engl J Med 2012; 367:938-943
Case Records of the Massachusetts General Hospital
Case 31-2012 — An 18-Year-Old Man with Blurred Vision, Dysarthria, and Ataxia
…toxins and drugs was negative. Computed tomography (CT) of the head was reportedly normal. The patient was admitted to the other hospital. A lumbar puncture was performed; tube 1 of the cerebrospinal fluid (CSF) appeared bloody, with gradual clearing. Reportedly, the white-cell count was 9 per cubic…
October 11, 2012
Yager P.H., Singhal A.B., Nogueira R.G.
N Engl J Med 2012; 367:1450-1460
Case Records of the Massachusetts General Hospital
Case 6-2012 — A 45-Year-Old Man with a History of Alcohol Abuse and Rapid Cognitive Decline
…lymphoma is less likely. Serum testing for toxoplasma and tuberculosis is not reliable in patients with advanced HIV infection. In this patient, lumbar puncture is precluded, given the anisocoria and the mass effect on the right midbrain. Glucocorticoids may temper the edema but might compromise the diagnostic…
February 23, 2012
Cho T.A., Larvie M., Tian D., Mino-Kenudson M.
N Engl J Med 2012; 366:745-755
…and he was transferred to a tertiary care hospital. Chest radiography and magnetic resonance imaging of the brain showed no abnormalities. A lumbar puncture revealed normal opening pressure. Cerebrospinal fluid protein and glucose levels were normal, and no cells were seen on microscopy. CT imaging…
June 7, 2012
Uttenthal B.J., Layton D.M., Vyse T.J., Schreiber B.E.
N Engl J Med 2012; 366:2216-2221