Case 325

A 76-year-old woman with a history of rheumatoid arthritis, Sjögren syndrome, and hypertension presented with a headache, fever, and dysphagia. The patient was taking prednisone and leflunomide to treat rheumatoid arthritis. Her headache was primarily left sided and occasionally radiated to the occipital region. The patient had a high-grade fever spike, with a temperature of 104°F (40°C). Results of a prior lumbar puncture and temporal artery biopsy from an outside hospital were negative. Findings of a neurologic examination were unremarkable. Oropharyngeal examination for dysphagia revealed minimal pharyngeal motility, with pooling of food in the pharynx, which was thought to be due to cranial nerve dysfunction. Laboratory analysis revealed that, except for anemia, complete blood count parameters were within normal limits. C-reactive protein level (49.7 mg/L; reference range, 0.0-8.0 mg/L), erythrocyte sedimentation rate (>140 mm/h with Westergren method; reference range, 0-27 mm/h), and brain-type natriuretic peptide level (145 pg/mL; reference range, 0-100 pg/mL) were elevated. Blood and urine cultures were negative. A lumbar puncture was performed, which revealed cloudy cerebrospinal fluid (CSF), with an elevated CSF protein level (78 mg/dL; reference range, 7.0-35.0 mg/dL) and a low CSF glucose level (37 mg/dL [2.05 mmol/L]; reference range, 45-70 mg/dL [2.50-3.89 mmol/L]); otherwise, CSF encephalopathy, an autoimmune panel, and cultures were negative. MRI and CT scans of the brain with paranasal sinus were performed (Figs 1-3). Nasal endoscopy-guided drainage of the preclival fluid collection was performed, and biopsy of nasopharyngeal tissue was performed. Fluid culture revealed the growth of Candida albicans, as well as Pseudomonas and Enterobacter aerogenes. The patient received fluconazole, ceftriaxone, vancomycin, and metronidazole. Follow-up MRI was performed after 2 weeks (Fig 4).