RSNA2018读片会病例挑战（1）：男，10岁，发热、疲乏5天，意识障碍

2018 RSNA

Image Interpretation Session

Neuro

10 y.o. old boy with fevers and fatigue x 5 days,    admitted due to altered mental status 

HR 123, BP 140/90 

Lumbar puncture 

• Opening pressure 35 cm H20 

• 194 nucleated cells/mL, 99% lymphocytes

 • protein 234 mg/dL 

• glucose 45 mg/dL 

Started acyclovir & broad spectrum antibiotics

Initial Evaluation

• History – viral prodrome

• Exam - Fever, HTN, tachycardia

• LP – lymphocytic pleocytosis, high

opening pressure

• RX – acyclovir, antibiotics

1 day later… 

CSF cultures and PCR come back negative;

continued tachycardia and hypertension

• Subtle central perivascular enhancement

• Leptomeningitis

3 days later…coma, flaccid paralysis

• Periventricular T2 worse, reduced DWI

• Longitudinally extensive myelitis

• Subtle spinal leptomeningeal enhancement 

Diagnostic Considerations: Meningoencephalomyelitis

Viral, Inflammatory, Vasculitis, Autoimmune

What would you do next to treat this patient?

Steroids, IVIG, Plasmapheresis… dramatic improvement !

• Walking with assistance 2 weeks later

• Maintained on IV steroids – deficits resolve (mild difficulty concentrating)

• Brain MRI normal on 6 month follow-up

• Normal CAP CT, scrotal US

T1+ T2

Differential Diagnosis

Viral

Inflammatory

Vasculitis

Autoimmune

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