3-year-old-fever

Figure 1 MRI 13/11/01 (on day 36 of chronic headache)	Figure 2 MRI 13/11/01 (on day 36 of chronic headache)

Course in the hospital:
Because of above findings she was treated with antituberculous drugs and dexamethasone for 2 weeks. The headache and low grade fever persisted. The repeated MRI (Figure 3) and repeated lumbar were done. The repeated LP demonstrated persistent high pressure, increased protein and low CSF sugar as shown in table 1

Table 1 data \ date	14/11/01 (before anti tuberculous drugs)	20/11/01	27/11/01	29/11/01
pressure O/C (cmHg)	30/20	14/11	29/26	36/18
WBC /cumm(PMN/MONO)	194(12/88)	138(18/82)	72(24/76)	26
RBC cumm	0	0	0	0
protein mg/dl	187	64	108	56
CSFsugar/Bl-sugar mg/dl	31/85	47/-	23/106	28/109
Gram stain	neg.	neg.	neg.	neg.
AFB stain	neg.	neg.	neg.	neg.
PCR for TB	neg.
India ink preperation	neg.	neg.	neg.	pos (figure 4)
CSF cryptococcus titer (Latex)	-	-	pos	pos 1:100
CSF cryptococcus culture	-	-	pos	-

Figure 3 The repeated MRI ( 27/11/01 ) showed a new hyperintensity lesion in the right globus pallidus, right thalamus on T2, could be from subacute hemorrhage.	Figure 4 India ink preperation shows bugging yeasts

Other immunologic investigations:
AntiHIV negative
C3 1066 ug/ml (550-1200 )
CH50 31.8 u/ml ( 20-40 )
IgG 1322 mg/dl 639-1349 )
IgA 138 mg/dl ( 70-312 )
IgM 262 mg/dl (56-352 )

Immunophenotyping: (Before starting antifungal therapy)

		Normal value
% Lymphocytes	25	-
% NK	14	-
% B cells	25	7-23
% T cells (CD3)	59	56-81
% T helper (CD4)	28	31-55
% T suppressor (CD8)	29	17-38
CD4 / CD8 ratio	0.97	0.84-3.05
Abs. Lymphocytes	1,258/ cu.mm.	>1,500/cu.mm.
Abs. T cells	742/cu.mm.	558-1,948/cu.mm.
Abs. T helper	352/cu.mm.	350-1334/cu.mm.
Abs. T suppressor	365/cu.mm.	147-812/cu.mm.
( WBC count	5,030/cu.mm.)	-

Prepared by....... Kamornwan Katanyuwong M.D Virat Sirisanthana M.D..
CC : Low grade fever and throbbing headache for one month.
PI : One month PTA, the patient developed low grade fever and headache. The fever had been noticed in the evening and at night time. She also had throbbing headache during febrile periods. She had no vomiting, blurred vision, nor ataxia. She was treated at a District Hospital with several courses of antibiotics including, amoxicillin, roxithromycin and doxycycline. Because of her persistent headache, she finally was refered to CMU hospital for further investigation and management.
PH : was unremarkable Significant PE
Temp 38 C, PR 98/min , RR 26/ min , BP 120/7/ mmHg Neurological exam Good consciousness No cranial nerve palsy, no weakness, no cerebellar signs Normal sensation Hypereflexia 3+ Blurred disc both eyes, no spontaneous venous pulsation. No stiffness of neck on admission Other physical exam appeared normal
Summary of problems
1. low grade fever 2. chronic headache 3. papilledema of both eyes
Laboratory investigation 1. CBC : Hb 13 g/dL , Hct 35 % , WBC 7,700 /cumm (N=62 , L=28 , M=9 ,E=1 ) Plt 373,000 /cumm 2. Electrolyte: Na = 138 mEq/L , K= 4 mEq/Ll , Cl =112 mEq/L, TCO2= 20 mEq/L 3. Chest X- ray: unremarkable study 4. ESR = 54 mm/hr 5. Tuberculin test: 0 mm. 6. Lumbar puncture (done on day 37 of chronic headache) : pressure O/C 30/20 cm.Hg, WBC 194/cumm (P12/L88), no RBC, protein 187 mg/dl, sugar 31mg/dl (Bl. sugar 85 mg/dl), India ink preperation was negative. 7. MRI (done on day 36 of chronic headache): hypointensity of temporal lobe on T1 and patchy hyperintensities in lt temporal lobe, lt thalamus on T2 , FLAIR. Abnormal enhancement after contrast (figure 1 and 2)