Paper
A 36‐year‐old man with headache and fever
Published Jul 1, 2018 · F. Pelorosso, M. Riudavets, A. Lía Taratuto
Brain Pathology
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Abstract
We present a 36-year-old cognitively intact male, with history of work-related solvent exposure who consulted for headache, vomiting and fever in September 2009. Symptoms persisted in spite of antibiotic therapy. CT scan showed a hypodense image in the left parietal lobe. MRI revealed a parietal lesion hypointense on T1, hyperintense on T2 and fluid attenuation inversion recovery (FLAIR), without mass effect (Figure 1A). Thoracic CT scan showed bi-apical interstitial infiltrates. Standard TB treatment was indicated along with steroids, obtaining a partial clinical response. Two months later, following steroid tapering, significant clinical deterioration was observed with fever, headaches and nausea. Patient was re-evaluated showing no changes on MRI. PCR testing for several microorganisms was negative. Differential diagnoses considered were: recurrent Meningitis NOS vs. vasculitis vs. ADEM (Acute Disseminated Encephalomyelitis). A new course of methylprednisolone was administered; after which patient requested voluntary discharge. In December 2009, patient returned with persistent fever and headache. A methylprednisolone bolus was administered and partial, transient response observed. At this time, the diagnosis considered was ADEM refractory to steroids, and treatment was switched to immunoglobulin therapy, which led to a complete clinical response. Once again, patient requested voluntary discharge, but had to be re-admitted later, due to headache, fever, mental confusion and aphasia in January 2010. New CSF PCRs ruled out viral diseases and TB. Other differential diagnoses considered included: Marburg’s disease, CNS lymphoma and Neuro-Behçet’s disease. The patient then suffered rapid clinical decline, developing limb weakness, somnolence and hyponatremia and died in January 2010.
Case ReportWork-related solvent exposure can cause acute disseminated encephalomyelitis, which can be treated with immunoglobulin therapy, but rapid decline and death are common.
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