Oh Oh Oh It's Magic, You Know…Never Believe It's Not So! (PDF)

A 72-year-old man with chronic sinusitis, obstructive sleep apnea, and recent extensive travel presented with right-sided headaches, vision changes, and allergy symptoms. A head CT demonstrated a sinus infection and he was treated with amoxicillin-clavulanate; and prednisone. His headache persisted and he presented to an ophthalmologist. Visual acuity was 20/30 OD and 20/25 OS, Ishihara color plates testing was 1 (test plate)/15 OU, there was no RAPD, extraocular motility was full. Anterior segment and fundus exams were unremarkable. Visual fields demonstrated a dense left homonymous hemianopia. Brain MRI revealed multifocal infarctions in the right parieto-occipital region. Further work-up was recommended; however, he left against medical advice. He followed up with his otolaryngologist who re-started him on corticosteroids. The patient developed confusion and agitation and returned to the ER. He was arousable to voice but required constant stimulation to maintain alertness. He had difficulty with repetition. His strength, reflexes and sensation were grossly intact. A CT demonstrated progression of his infarction and a left-sided parotid mass. His bloodwork was normal. He was started on empiric intravenous antibiotic and antiviral treatment, later broadened to systemic antifungals. An MRI with contrast demonstrated new leptomeningeal enhancement and new cerebral and cerebellar infarcts. Lumbar puncture demonstrated an opening pressure of 46 cm H2O with straw colored fluid. Constituents: WBC 14 (65% lymphocytes, 16% monocytes, 19% eosinophils) RBC 38, protein 225 (N<50), glucose 63, IgG index 1.0 (N<0.6), and 2 unique oligoclonal bands. An extensive infectious, neoplastic, and autoimmune work-up was negative. An echocardiogram was normal. CT scan of the chest, abdomen, and pelvis demonstrated a few small pulmonary nodules. His neurologic exam continued to worsen. He developed bilateral optic disc swelling. Repeat neuroimaging and lumbar puncture demonstrated new areas of infarction and persistently elevated opening pressure and a similar CSF profile. A diagnostic procedure was performed.