A 43-year-old man was admitted to the hospital because of fever, headache, malaise and confusion. His colleagues who brought him to the hospital reported bizarre behaviour and difficulty in communication. His temperature was 38, 5°C, blood pressure 135/70 mmHg, pulse rate 90/min, sinus rhythm. Under examination the patient was alert, but slowly reactive and disorientated. Except for stiffness of neck, the rest of his physical examination was unremarkable.
The patient was single, living with his brother and mother, and worked as a truck driver with international freight. His sexual preference is unknown. He smoked regularly one pack of cigarettes per day for 25 years, drank occasionally and smoked marijuana from time to time.
Five years ago, he was admitted to another hospital because of bilateral facial nerve palsy, which resolved. One month ago he had another bout of confusion, and for several months he had a dry cough.
A C/T of the brain was normal and a chest X-ray was unremarkable. A lumbar puncture was also performed. The CSF was clear, colorless. The cell count was as follows: Cells per mm3: Red 10,200, White 2(lymphocytes). Protein concentration was 45 mg/dl and glucose was 95 mg/dl, while blood glucose was 236 mg/dl. The hematocrit was 36.7%, white cell count 5700 per mm3, (neutrofils 69%, lymphocytes 19% monocytes 8%), platelet count: 196,000. BUN was 33 mg/dl and creatinine was 2.7 mg/dl. There were no other laboratory test results of significance.
The patient was prescribed cefuroxime and on the following day his mental status improved. He could eat and cooperate properly under physical examination. Suddenly, on the third day, fever rose to 39, 5°C the patient became comatose (GCS 7/15) and his blood pressure was 60/40 mmHg, pulse rate 85/min. Dopamine and then Dobutamine was administered. The patient was intubated, mechanical ventilation was introduced and he was transferred to the ICU.
Cefuroxime was discontinued and cefepime, vancomycin, amikacin and acyclovir were administered. A second lumbar puncture was then performed. The CSF was purulent in appearance. The cell count now was as follows: white cells 38.000(neutrofils 98%, lymphocytes 2%) protein: 1,5 gr/dl and glucose: 8 mg/dl, while blood glucose was 150 mg/dl. Microscopical examination: intracellular gram (-) rods. White cell count indicated 7100 per mm3 (neutrofils 81%, lymphocytes 10%, monocytes 5%).
The culture of the first CSF specimen yielded salmonella enteritidis susceptible to ciprofloxacin, second and third generation cephalosporins. Hence ciprofloxacin was added, while acyclovir and vancomycin were discontinued. An Eliza reaction for HIV was performed and showed positive. The results were confirmed by Western-Blot reaction. The following day a blood culture also yielded Salmonella enteritidis. The CD4 (+) cells were 16/mm3.
On the eighth day after admission the patient died with refractory shock and multiorgan failure.