Extensive subcortical white matter, deep grey matter and brainstem oedema in a confused patient: Question

Abstract

•Striking and extensive MRI brain changes are presented.•Expanding the radiological spectrum of MRI brain changes in cerebral lupus.•Consideration of an inflammatory CNS process in the diagnosis of encephalitis.•Role of early and aggressive steroid treatment in Cerebral Lupus. A 70 year old female presented with a history of headache, confusion, drowsiness and impaired mobility. Her past medical history was notable for haemolytic anaemia and a left-sided occipital infarct two years previously. On examination she was noted to be confused with a fluctuating level of consciousness. No focal neurological signs were observed. She was not meningitic. An initial CT head showed an old left occipital lobe infarct. A CSF examination demonstrated a white cell count of 25 × 109/L (100% lymphocytes), a raised protein of 1.7 g/L and a glucose 3.9 mmol/L. Viral PCR was negative for HSV and VZV. Her conscious level deteriorated culminating in a drop of her Glasgow Coma Scale (GCS) to 7 (E2, V2, M3) necessitating admission to the intensive care unit. She underwent an MRI brain which demonstrated extensive subcortical oedema affecting the white matter tracts, deep grey nuclei, brainstem and cerebellum with several foci of microhaemorrhages (Fig. 1A and B). MCQ: What is the most likely diagnosis?(a)Viral encephalitis(b)CNS Lupus(c)Lymphoma(d)Multiple embolic infarcts Answer on page 174. Extensive subcortical white matter, deep grey matter and brainstem oedema in a confused patient: AnswerJournal of Clinical NeuroscienceVol. 41PreviewAutoimmune serology demonstrated an ANA titre 1/1280, and dsDNA titre of 60 with strongly positive anti-cardiolipin IgG. In addition she had a history of haemolytic anaemia and a malar rash. A unifying diagnosis of CNS lupus was made [1]. Full-Text PDF