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).