Infectious Disease
Case 6: A Patient with Presumed Infection and Confusion
CASE
A 55‐year‐old woman had been previously fit and well. She was brought into hospital via ambulance with acute confusion and drowsiness. You were told by her son that she had a preceding history of headache, malaise and numerous cold sores on her lip. She had no past medical history, no recent foreign travel and did not take any regular medication.
On examination she had a temperature of 39°C, a heart rate of 100 beats/min and an arterial blood pressure of 110/80 mmHg. Her respiratory rate was 18 breaths/min with an oxygen saturation of 98% on air. She was restless and very confused. Her Glasgow Coma Score was 11 (eye 4; voice 2; motor 5). She was unable to cooperate with a neurological examination, however you observed that she was moving all four limbs equally, both plantar reflexes were down‐going and there was no meningism or rash. You also observed numerous herpetic lesions on her lips. Examination of her respiratory, cardiovascular and abdominal system was unremarkable.
The following results are obtained:
Hb 13 g/L WCC 20 × 109/L Platelets 240 × 109/L CRP 220 mg/L ESR 60 mm/h U&Es Normal LFTs Normal CSF Appearance Cloudy Microscopy No organisms seen WCC 2000 cells/mm3 (98% lymphocyte) RCC 30 cells/mm3 Biochemistry Protein 0.7 g/L Glucose >50% plasma level
Blood culture: no growth
Chest X‐ray: clear
QUESTION 1
Your score this session: 0 of 0
What is the significance of the herpetic lesions?