A 73-year-old female was brought to hospital in unresponsive state, following six days of headaches and fevers. Her blood pressure was 90/50 mmHg, and Glasgow Coma Scale was 4, necessitating intubation. Examination revealed comatose state, left gaze deviation, and no response to noxious stimuli in right extremities.
Initial stroke assessments, including non-contrast CT, CT angiogram and perfusion, were unremarkable. Due to unknown last known well, she wasn’t a candidate for thrombolytics. Bloodwork showed mild leukocytosis, diabetic ketoacidosis, and uremia. She was admitted to ICU and started on antimicrobials with meningitis coverage.
Blood cultures grew SAG. CSF studies on day three suggested bacterial meningitis. CSF cultures, gram stains, and panels for meningitis/encephalitis and paraneoplastic syndromes returned negative, leading to discontinuation of antivirals. Although her metabolic issues improved, her neurological status declined. Long-term EEG revealed no seizures.
MRI was not performed due to incompatible spinal nerve stimulator. Subsequent CT scans revealed evolving infarcts in left internal capsule, bilateral thalami, and midbrain. With no additional sources of infection identified, and after discussions with family, she was transitioned to comfort care.