Dr. Karthik Arif (Neurology) needs a second opinion on this medical case.
58yo M w/ h/o 2 colonic adenomas (removed), questionable throat cancer, lumbar fusion, and cardiac arrest approximately 6 years ago, who p/w headache, photophobia and wt loss of 30 kg over the last year due to dysphagia. SocHx: opiate abuse, marijuana use, but does not inject. Quit smoking 10 yrs ago, but prev mult packs. . On initial presentation, minimally interactive and participatory with exam, oriented only to person/place. No nuchal rigidity or focal neuro deficits. Following adm: R eye became injected and he developed a CN VI palsy. No derm finding suggestive of malignancy or emboli. Based on multiple brain lesions on CT/MRI initially suspicious for malignancy, steroids started. HIV neg. LP showed no evidence of malignancy, only mild lymphocytic pleocytosis (WBC 41). Progressive chemosis of R eye led to concern for endophalmitis. Vitrectomy performed but micro was neg and pathology showed only acute inflammation. Blood cx (including AFB and fungal) neg. Cocci, histo and blasto ab neg. Serum ACE neg. Empiric abx started: vanco, metronidazole, ceftriaxone, SMX/TMP. Ampho B also started, but later stopped due to RTA and lack of clinical response. A craniotomy was performed to obtain a biopsy from one of the left frontal lesions. Culture grew E. faecium. PET was neg for malignancy... Still unknown: primary source?