64 year old Female with history of poorly controlled Diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea, coronary artery disease, transferred for episodic aphasia. Initial blood pressure 168/103, afebrile. Physical exam showed skin fold candidiasis, lower extremity chronic erythema and skin changes. CT head unremarkable. Labs significant for hyperglycemia of 540 and sodium of 130. Treatment initiated for hypertension, hyperglycemia and fungal infection. Day 2, patient developed transient symptoms of aphasia and confusion resolving rapidly. CT head, CTA head/neck, MRI brain with/without contrast showed chronic white matter changes and 5mm focus of contrast enhancement in right Thalamus thought to be developmental venous anomaly.
Initial neurological exam day 3 significant for 10-15 second bursts of aphasia with neologisms when speaking, reading, repeating, and naming or describing images. Notable weakness in hip flexion bilaterally with right 3/5 and left 4/5, chronic in nature. Continuous video EEG monitoring initiated. 6 hours later patient found encephalopathic with rapid deterioration in ability to speak, read, repeat, identify images. EEG showed diffuse slowing with no seizures. Patient started on IV acyclovir 10 mg/kg three times daily. Day 4 patient improved to baseline. Day 5 Lumbar puncture CSF studies showed elevated protein of 175, glucose 78 (serum 164), 4 rbc, 338 nucleated cells (lymphocytes 76%). Gram stain with few polymorphonuclear leukocytes, many mononuclear cells. No growth on bacterial culture. PCR panel detected varicella zoster virus. Patient received 4 days of IV acyclovir followed by oral valacyclovir completing 10 day course of treatment.