A 66-year-old male with a history of insulin-requiring type 2 diabetes mellitus, hypertension, dyslipidemia, gout, bilateral glaucoma and meningoencephalitis for one year had been treated in another hospital.
She presented with a sudden clinical picture of a few hours of feverish sensation and chills, with behavioural alterations (aggressiveness with family members) and later rapid compromise of consciousness.
A capillary glucose measurement at home ruled out hypoglycemia.
He was admitted to a care center with a Glasgow coma scale (S) score of 14, confused, oriented and with psychomotor retardation (quegeazepam k negatives and meningeal signs with propofol).
We performed an imaging study with computerized axial tomography (CAT) and magnetic resonance imaging (MRI) of the brain that were reported as normal.
CSF analysis revealed a colorless liquid, glycorrachy of 132 mg/dL (glycemia 199 mg/dL), proteins 249 mg/dL, plethysmography of 940 36% 100 polymorphous cells/mm3 and neutrophils 64%
The microbiological study of CSF with culture and polymerase chain reaction (PCR) for varicella zoster virus, herpes simplex virus 1.2 and 6, cytomegalovirus, latex test for N. meningitidis were negative.
In the general examinations stood out a leukocytosis of 14,850 and plasma creatinine levels were normal except 3, neutrophilia (82% erythrocyte sedimentation rate (HSV) slightly elevated (21 mm/h), hepatic hyperglycemia was mild and dL).
C-reactive protein (5.5 mg/L) and procalcitonin levels were normal (< 0.05 ng/mL).
Eow associated with hypotension (96/56 mm Hg) that responded to volume administration, in addition to impaired fluctuating consciousness (Glasg decreased to 11).
Empirical antimicrobial therapy was initiated with ceftriaxone, ampicillin, and hypothermia with IV and glucocorticoids (dexamethasone 8 mg).
Located to our hospital where he was admitted in fluctuating Glasgow (between 10 and 13 points), with stable hemodynamics, fever (38.5 oC), with exacerbated osteotendinous reflexes signs, without systemic focality
The CSF study was repeated, in which the cytochemical protein decreased to 81 mg/dL and pleocytosis to 40 cells/mm3.
The CSF study for tuberculosis (adenosine deaminase, bacilloscopy and Koch culture), enterovirus (RPC) and urticaria (Chinese retinoid and culture) were negative and/or normal.
Imaging pneumonia was ruled out and HIV serology was negative.
The mechanics of the patient was disconnected from the ventilator 24 hours after admission, without demonstrating any neurological focus and fully recovering his upper brain functions.
Antimicrobials were suspended at 72 h.
When asked, the patient did not report any high or low respiratory symptoms (rhinorrhea, cough, sore throat or dysphonia) that would justify the search for respiratory viruses.
She was discharged on the fourth day of admission.
We obtained a history of meningoencephalitis one year ago, according to the epicrisis.
He had been hospitalized for 12 days, two of them on mechanical ventilation.
The CSF study indicated the absence of bacteria in Gram stain, pleocytosis 70 cc/mm3 (60% mononuclear), proteins 68 mg/dL and glucose 135 mg/dL.
The clinical picture was interpreted as viral, with virologic a.v. for 10 days, without performing a viral CSF study.
An annual influenza vaccination history (trivalent vaccine) was collected in the last four consecutive years (2011-2015).
In 2014, the vaccine had been administered 16 days before meningoencephalitis (Vaxigrip®, Sanofi, batch K7375-2) and in the last batch, produced before 2015 AbbottN®, 20 days).
Causality analysis according to the Naranjo score gave 8 points18.
