- Case studies
- Revision notes
- Reading list
- Your Feedback
- Become a reviewer
- Student Apps
- More student books
- Join an e-mail list
A 44-year-old man who presented with an episode of collapse described a 2-week history of fatigue, agitation, confusion and left arm weakness, but no headaches, visual problems, vomiting, seizures or dental pain. On examination he is found to be febrile. He has a reduced level of consciousness.
1. What is the differential diagnosis?
Reduced consciousness and fever should make one consider bacterial meningitis, cerebral malaria, brain abscess or cerebral haemorrhage
2. What does the absence of papilloedema suggest?
The history of this presentation is short so the absence of papilloedema does not exclude raised intracranial pressure.
3. What investigation is required now?
A CT scan is necessary to determine whether there is any raised intracranial pressure.
4. What is the most appropriate treatment?
The patient should be commenced on a regimen that includes a third-generation cephalosporin and metronidazole.
5. What additional treatment should be considered?
For diagnosis and therapy the abscess could be drained.
6. How would you interpret these results?
The molecular identification is more likely to be correct. Streptococcus parasanguis is usually found as a commensal in the mouth, whereas Streptococcus intermedius is capable of causing abscesses throughout the body.
7. How would these results affect the treatment?
The streptococcus will be sensitive to the cephalosporin and treatment should continue as before.