Crack the Case: Seizures, Fever, and a Fatal Outcome

Neuropathology for Neurologists

James W. Mandell, MD, PhD


September 09, 2013

Clinical Presentation

A 32-year-old white woman presented to the emergency department (ED) with thoracic and upper-limb muscular pain. She reported having had root canal surgery 2 weeks earlier. While in the ED, the patient showed evidence of a focal seizure involving her left arm, progressing to a generalized tonic-clonic seizure, followed by loss of consciousness and respiratory failure requiring intubation. She subsequently had spiking fevers to 104°F and never regained consciousness.

Multiple examinations of serum and cerebrospinal fluid (CSF) failed to reveal evidence of bacterial, rickettsial, or viral infection. The patient was treated empirically with intravenous antibiotics and steroids, but she soon developed disseminated intravascular coagulation with subsequent multiple organ failure and died 8 days later.

Autopsy Findings

The dura mater was unremarkable, with no evidence of venous sinus thrombosis. The brain weighed 1225 g and showed vascular congestion but no hemorrhage. The leptomeninges were free of infiltrates. The base of the brain revealed herniation of the right uncus and both cerebellar tonsils. The large vessels of the anterior and posterior circulation were unremarkable, as were the cranial nerves and brainstem.

Figure 1. Hematoxylin/eosin-stained section of hippocampus. Image courtesy of James W. Mandell, MD, PhD


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