Case History & Examination:
A 40-year-old Caucasian woman presented to the emergency department complaining of fevers, worsening shortness of breath, and new-onset witnessed tonic-clonic seizures. Her medical history was significant for mental retardation, tobacco usage of 40 pack years, chronic obstructive pulmonary disease diagnosed in her 30s with a 2L O2 home oxygen requirement, and multiple complicated previous hospitalizations for various infections. She also endorsed two months of unwitnessed syncopal episodes, headaches with intense pain over the left eye, worsening dyspnea with exertion (able to walk 15 feet from a baseline of 100), cough producing yellow sputum, and weight loss. She had no associated photophobia, neck rigidity, or blurred vision. On physical exam, she was febrile to 103ºF, tachycardic, and hypoxemic despite home oxygen support. She had diffuse crackles throughout both lung fields; subsequent chest x-ray showed expanded lung fields consistent with the patient’s known COPD, and a diffuse reticulonodular infiltrate suggested by CT scan to be necrotizing pneumonia with cavitation. Brain MRI revealed multiple scattered intra-axial ring-enhancing lesions in the left posterior frontal lobe, left posterior parietal lobe, right occipital lobe and left temporal lobe, all with restricted diffusion and surrounding edema (Fig 2).