Searching for the Source: Bacteremia with Marked Cerebrospinal Fluid Pleocytosis

Abstract

PRESENTATION Serious illness did not impede a 65-year-old woman’s daily activities—until she developed an infection that was difficult to pinpoint. The patient presented with a 1-week history of fatigue and confusion. She had a 20-year history of autoimmune disease and related immunosuppressive therapy, beginning with a diagnosis of seropositive rheumatoid arthritis in the late 1990s. This was associated with Sjogren’s syndrome, confirmed by positive tests for anti-SSA/Ro and anti-SSB/La antibodies. Control of her disease required a series of disease-modifying antirheumatic drugs that, over time, included prednisone, methotrexate, leflunomide, etanercept, rituximab, and abatacept. Five years before admission, the patient had a right axillary mass that was diagnosed as large B cell lymphoma. She was treated with a regimen known as R-CHOP, which consisted of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Two years before admission, she reported severe left hip pain, determined to be a consequence of Salmonella septic arthritis. She underwent debridement and intravenous antibiotic therapy, and ultimately, a prosthetic hip was placed. Six months before presentation, she received simeprevir and sofosbuvir for hepatitis C infection. Despite her medical comorbidities, the patient lived alone and took care of her own finances, shopping, and driving. She enjoyed spending time with her grandchildren, and she was highly functional, independently traveling out of town by bus to visit her family 1 month earlier. One week before presentation, she began to experience fatigue so overwhelming that she was falling asleep during the day—even during conversation. This