By Clare Di Bona

 25yo BIBA  “Pseudoseizures” found slumped in a chair stiff, LOC 2 minutes  No post-ictal phase, no incontinence  ED waiting room generalised seizure  PMH depression on escitalopram. Has used methamphetamine in the past  GCS 11/15  Eyes open spontaneously4  Groaning 2  Localising to pain5  MRI Shows cerebral oedema

 CSF  Appearance: clear and colourless  Cell Count Leucocytes 88/uL Polymorphs1% Lymphocytes99% Erythrocytes2  Biochemistry Protein0.21g/L ( ) Glucose 2.8 mmol/L ( )  Microscopy no bacteria seen  Culture no growth  High Anti-NMDA level

 Dropped GCS 3/15 in coma ICU  Ongoing pseudoseizure activity with facial twitching and finger movements  Autonomic dysfunction persistent tachycardia and fever despite normal WCC and CRP  IV immunoglobulin and plasma exchange no effect  50% association ovarian teratoma, US showed no evidence of this…ovaries taken out and found to have microscopic evidence of teratoma  Slow but steady clinical improvement following this.

 36 yo 5/7 insidious onset generalised headache  No recorded temperatures but getting hot/chills at home  Vomited at home  No photophobia, no meningism, petechial rash  Recent fishing trip-lack of sleep, alcohol++  Nil significant PMH  GCS 15/15 looks well from the end of the bed.  Normal CRP, normal WCC

 Appearance: turbid  Cell Count  Leucocytes 2580 /uL  Polymorphs 20%  Lymphocytes 80%  Erythrocytes 24 /Ul  Biochemistry  Protein 0.99 g/L  Glucose 2.8 mmol/L ( )  Microscopy No bacteria seen  Culture no growth

 Enterovirus/ Rhinovirus RNAnot detected  Herpes Simplex virus 1not detected  Herpes Simplex virus 2not detected  Neisseria meningitidisnot detected  Varicella Zosterdetected  Streptococcus pneumoniaenot detected

 Ideally blood cultures and CSF prior to IVAB  Should not delay the commencement IVAB >30minutes  Dexamethasone 10mg IV before or with first dose of IVAB PLUS  Ceftriaxone 4g or cefotaxime 2g Add  Benzylpenicillin is suspect Listeria (immunocompromised, >50yrs, alcoholic, pregnant)  Vancomycin is suspect pneumococcus (gram +ve diplococci, otitis media, sinusitis, treated beta lactam)